Travis County

Agenda Item

Receive update from the Travis County Healthcare District DBA Central Health regarding the District’s upcoming FY 2020 budget and report of services provided.
(Judge Eckhardt)


Department:CC Agenda requestSponsors:
Category:General Government

Meeting History

Jul 30, 2019 9:00 AM Video Commissioners Court Voting Session
draft Draft

Members of the Court heard from:

Mike Geeslin, President and CEO, Central Health

Yvonne Camarena, Chief Operating Officer, CommUnityCare

Jeff Knodel, Executive Vice President, Financial Strategy, Central Health

Wesley Durkalski, President and CEO, Sendero Health



Jul 30, 2019 9:00 AMVideo (Windows Media) MP4 VideoCommissioners CourtVoting Session

1:31 PMComplete the rest of our

1:31 PMAgenda. &j
Good afternoon and welcome to the July 30 commissioners court. Next is agenda item number 28. Commissioners and Commissioner Daugherty will join us jointly. This is just an update. No action necessary by the commissioners court today. Thanks so much. I will state with the record we did take some action on the consent motion to mirror our tax exemptions that we provide to residents as well.
1:32 PMThank you.
And that voted positively. Take it away, y'all.
Good morning, Judge And commissioners. I'm president and ceo of central health and we want to thank you for having us here today to provide you this update. Central health is the health care district for travis county. We currently provide in some way shape or fund health care for one in seven travis county residents. Joining me here today I have yvonne from community care and jeff. We have at least one board member present that I can see behind me, manager greenberg. Now, the presentation today, if I could best summarize it, we'll talk about what we've done, what we're going to continue to do through the rest of this fiscal year and into fiscal year 2020 and some of the big pack force affecting our fiscal landscape and how we deliver care. There's a number of issues external to central health that will change the way we fund health care in travis county. This way you will have context and back drops so when we do come balk -- back in late august, you will have a sense of what's driving the numbers that you will ultimately see. First I want to remind the court this 2017 we had a performance review. This was a review urged by this court. That review was conducted throughout 2017 and concluded and presented in 2018. And there are some categories that you'll see throughout this presentation that touch on this performance review. One is improving specialty care access. Transparency of funding and services relationships. Increasing awareness of how central health delivers care. And then for sendero, the recommendation was fined ways to optimize the use of sendero and in this case it involves taking advantage of the federal risk pool system to be able to fund parents to have the option to be in either m. A. P. Or sendero ideal care. For fiscal years 2018 and 2019, some of the highlights, we had a 31% incease in people who had received health coverage screening and assistance in fy-18. Patients?
1:49 PMSo in this particular model what we're looking for is this program is specifically for the community as far as patients that live in the area. We do partner with the schools so that in the sense that we're good partnership, but as far as health for the particular teachers, that is something that we haven't put into this particular model. But as far as being there if they had any urgent issues, we would always be there to help anyone who needed our support.
1:50 PMOkay. i'm interested in looking at the model particularly the school based model so that if we've got kids -- and if their teacher is there as well, the teachers get to use those facilities. I'm interested in the feasibility of that. And then i'm interested in patients -- parents as well. If I can get my child seen there and then I can go there too, if I live in colony bus, I don't have to get on the bus for four hours, I can just go to overton school and get that addressed. I'm interested in the level of cares re provide at schools and whether we can address the needs of teachers.
1:51 PMThis first one that we're partnering with akins, isd is folks focused on the students and the families of the community. That's this first phase. I will definitely take the information that you are providing to us in your interest and we'll continue to do that research.
Thank you.
Is this time for questions?
Is there more presentation?
Why don't we try to get through the presentation and then have questions.
Thank you, jeff, cfo with questions.
2:01 PMCommissioners?
Go ahead.
I wanted to go back to the chart on measuring progress in my -- in primary care. That's an impressive growth rate. It's the chart that shows the total primary care visits increasing. That one. It looks like it's doubled, maybe a little more than doubled from 2005. Is that correct?
2:02 PMYes.
Which is really impressive. Was the starting number in 2005 essentially the old m. A. P. Patients, the number of old m. A. P. Patients that were being seen. Were you seeing almost 200,000 patients in 2005? I'm trying to remember when central health got up and running. So that number probably was the old m. A. P. Patients. Medical assistance people are nodding. I'm trying to get some frame of reference where that number could have came from.
Both the m.a.p. patients and the clinics that were transitioned by the city. At that time there would have been grants and sliding fee scale type patients.
There were probably walk-ins that weren't part of the m. A. P. Program. I want to acknowledge. I feel there were a lot of questions, people are frequently coming to this court and I discussed some of this with you yesterday with concerns, the wait times on the specialty care, what type of services was the public getting and I think you've been very responsive, worked really hard to increase access to specialty care and I think it shows people are not coming to the court and regularly raising these issues so I really want to acknowledge the work you all have done to improve access to care. And also to provide the care where the community really needs it. I think you are making real progress there. I did want to ask on the previous year, 2018-2019, the 31% increase in people who received health coverage screening and assistance, do any of these numbers include people who are also getting access to care through sendero? Do any of these statistics include that population?
2:03 PMI'm not advised but jeff, do you --
2:04 PMI don't think they do.
So that 31% increase is through the central health clinics, community care clinics, those locations or the private screenings.
I wouldn't include the enrollments.
And that expansion of medical access program and launch of m. A. P. Basic, how does that relate to sendero? That's what i'm trying to understand. Is there any relationship there? Not really - people are shaking their head no.
Health funding programs.
But m.a.p. is the essentially lower income population from there's some to shift to sendero like the 2 # 23 people moved to sendero earlier. I did have a question about that. If the cost was higher than expected on those m. A. P. -- I mean on those sendero claims, phrase claims costs more than anticipated. Can we assume that -- some large percentage of that came from the m. A. P. Parents who newly moved over to sendero? Is there -- is that probably accurate?
2:05 PMSpecifically it was those patients.
It was those patients.
So had they stayed in the m. A. P. Program, is it fair to say the m. A. P. Program would have incurred higher costs? From those patients?
They would have incurred costs related to the treatment of those patients, yes.
But would it have been higher than anticipated or was it simply given the trajectory sendero was on you weren't appearing those costs. I'm trying to understand how it was higher than anticipated.
I think we had estimates based to acuity of the patients and they simply were higher than we anticipated. I think we're trying to work through some of the data to understand that better.
And part of what i'm trying to understand is my -- my recollection from some of the performance review that encouraged greater transfer or encouraging next from m. A. P. Who were very ill to transfer to sendero bass because sendero got a much higher reimbursement rate than the m. A. P. Program.
2:06 PMThat's correct. it's another strategy we would have to try to leverage federal funding. This one typically we do it through other hospital based programs. This is just a sendero strategy that utilizes the aca risk adjustment.
So had those people remained in m. A. P. And not transferred over to sendero, there would have been a higher cost to central health to provide this care to them?
Yes, to provide the services.
It seems to me the strategy of trying to get these m. A. P. Patients into sendero and take advantage of the more robust reimbursement rate is a really a smart one fiscally but also provides those folks access to a more robust clinic network or access to more services? That was part of my understanding of the benefit of having these people transferred to sendero. It would be an improvement in their access to care. Is that fair?
2:07 PMCorrect. and brings down more funding to make that possible.
That's probably the biggest success that we're happy about. You know, the goal was to bring down more funding to extend access to care for these people. That is definitely happening.
And so will there be more of an effort to try and identify more folks who are in this chronically ill category and encourage them to transfer from m. A. P. If there are any still left in the program to transfer over to sendero?
We will have budgetary resources to examine that, but there's a lot of risk -- it's a good strategy, but have you to make sure you implement the strategy correctly. We are looking at it, we plan on allocating some budget, teri resources in order to look at expanding the program if it makes financial sense to do that. So we're evaluating the acuity, the risk scores of some of our existing m. A. P. Population and we'll look at aca always has risk involved in it, seems like almost a day-to-day basis, but certainly year to year. So we'll evaluate everything based on the most recent data that we have and use what we learn in the transition for this year to try to improve it even more next year.
2:08 PMSo i'll be interested in just sort of periodic updates where all that stands because it seems like this has been beneficial both for the people who are really sick and who can't really afford access to care.
And just as a reminder, commissioner, we're only six months into the transition so we're using as up to date data that we have, but there's still six more months in the sendero fiscal year. It's a calendar based year. So we're really using data up through June to project what the rest of the year looks like. So I just wanted to always caveat --
2:09 PMIt's not the complete year. I think that's it, but congratulations on responding to the concerns of the community and providing more access to specialty care and really putting the health care where needed.
And I understood the last time that we had a real serious discussion with y'all was that 500 was the goal to have on sendero, correct? You all remember that?
What was the goal?
It was 500.
Seriously ill individuals and it fell short, but you got people way sicker, right?
So -- not necessarily. I think it fell short of that, but I think it was only because of the time line. It wasn't because of a lack of operations or interest on the part of the candidates or anything. So it was a good -- in a sense it was a good pilot for the 220 and now it's up to how well it fits into central health's plans and whether we expand it.
2:10 PMThe funds you all have in your budget to address further recruiting, basically, of people to get on sendero, will those funds be sufficient to reach a higher goal?
So for our proposed budget, we will budget for 500 and adjust accordingly based to information we receive and as our bedder deliberates options that May exist.
So how much money do you all think it will take to recruit more?
Premiumwise, for 500 members, it's about $8 million.
2:11 PMOkay. okay. And I don't know what we were paying when we were covering m. A. P. Patients, but it was certainly one of our main mandates. And so when you all came along, we kind of passed that over to y'all, along with the tax money, i'm sure.
And I think we've discussed other issues that are germane to southeast travis county. I'm really looking forward to having those come on board.
Thank you.
Before long.
Mike, I -- while I don't want anything to leave east and southeast travis county, the thing that is glaringly, you know, obvious in these kind of presentations is I represent 40% of travis county, western travis county, precinct 3.
2:12 PMYes, sir.
And there are areas in western travis county that, quite frankly, need services. It's probably more my fault for not sitting down with you and saying hey, what are we going to do. I recollect couple four years moved a clinic out of jonestown. Jonestown is probably a pocket of people financially pretty strained. And, you know, the lakeway area, there's apache shores, there's cardinal hills. You know, there are folks there too. I mean, you know, the oxygen gets sucked out of the room in this -- in your world because there is such a great need east and the growth that's going east because affordability of being able to go out there. But I do want us to look at paying, you know, some particular attention to a couple of spots out there. When you all make a payment to seton or whoever, is there a menu of cost that you all get before you have to pay something? I mean if somebody needs this, can you look at a menu sheet and go, okay, that costs this much from this organization? Is that something that you all get?
2:13 PMSo --
If it were only that easy.
It should be a lot easier than it is.
Right. and when you look at hospital processing, it's a complicated matrix of charge masters and there's a whole -- i'm not going to get into it because i'm getting way out of in terms of my understanding of that, it's extremely complex. Right now there indirect fund, it doesn't work that way. I think what Mr. Canola was pointing out, as we transition to more of a claims based and transactional model, that we've start to see what those costs are. We can even take it a step further. I don't want to get too far ahead of this, but after some period of time of operating under that model, we could start to develop case rates where we do have greater transparency and what those costs actually are. I don't know if you wanted to provide insight.
2:14 PMWe might be able to give you some help. We ought to. The industry is moving that way. The industry is moving towards, you know, forcing, you know, the hospital organizations to say, no, you've got to tell us. I mean, you know, I thought I was out of the woods on some procedure that I had and out of left field comes a $700 bill to me. I know Commissioner Shea had the same thing happen to her. Y'all got to be faced with the same kind of stuff. So, you know, we're all in this together. And so I think it's going to take some prodding, you know, from some of us, you know, to approach, you know, the hospitals. You are right, it's very complicated. I mean, you know, kinds of like reading a bunch of bills that you get, you are like I don't know what in the world that even means. But if we can -- if we can give you some help, then let us know. Because I think it would help you all as well. The unfortunate thing is that to me it -- the salvation for sendero is to have a bunch of sick people leave m. A. P. And run to sendero. Because that's the only way that it kind of gets propped up. I mean, you know, because of the draw down and who knows what's going to happen, you know, with aca. But, you know, it's real obvious even if you have some extraordinary costs, it's like you got to do whatever you got to do to get people out of m. A. P. And into sendero. Just the draw down. Isn't that pretty right, wes, isn't that how it works, or mike?
2:16 PMGo ahead, wes.
Correct. for the sick people, it makes sense.
Makes sense for both. makes sense for the sick people --
No question about it.
And makes sense for central health as it relates to sendero.
So we have access to funding through aca, as long as it's here. We have access to funding for sick people. Makes perfect sense to use it, reduce the burden on central health, stabilizes their health too. In this case it's sick people where they can just pay premiums instead of playing claims. So there's some balance and that's what we will continue to work towards.
2:17 PMCommissioner, if I may, it is a balancing act though, and you are right, the name of the game is to give those m. A. P. Patients the opportunity to select sendero based on their risk score. But we have to balance this very carefully over time. As Mr. Canola pointed out, we're got six months of actuarial work so we're constantly looking at that, but also getting outside actuarial opinions even beyond because the last thing we want to do is set up programs that are not sustainable. It was not in the too distant past that sendero had to withdraw from a market in this region. And it is very disruptive to people's lives whenever you do this. We want to be responsible and make sure whatever products and programs we put out there they are with people year in, year out and don't have to worry about it.
Other questions?
2:18 PMI have one question.
Commissioner Shea.
In the past we've talk about services at the jail. This seems like a really obvious one where the community direct investment of the 35 million a year May also pay dividends. I know you were working on providing additional services. Is there any update in that area that you can provide? At the travis county jail where we have a permanent population -- not permanent, but a population that has a trend line of staying longer and they are sicker. So we can guarantee your patients will show up for an appointment.
Right. I don't have an update for you today in terms of what all any of our clinical partners might be working on, but let me look into that and i'll have to get back to the court.
We have had conversations with dell medical school, but I thought it was also in the context of larger -- any updates would be helpful. How did the transition move for the blackstock clinic go? There were concerns because they were so close to the medical school that there might be disruption when I moved to the southeast health and wellness clinic.
2:19 PMActually the transition went about as well as we could have hoped. We're checking the numbers now. The majority so far of on our patients moved along with us. It would probably take a few more months. As far as the patients, they are able to make their appointments. They have access to additional services that they didn't have before and I think that's also been very helpful at our southeast health and wellness location we have a mammography unit, we have x-ray. There's care management, our behavioral health counselors, our nutritionists, central health services around the zo omba class. We also partner with the texas food bank as well. So you have the volume of services along with our convenient care location that's there and we have a pharmacy on site. So you can see by the large number of services that they have that the patients suddenly they really do have a complete set of care delivery that he they didn't have in the previous location. And I think you are beginning to see, our patients are beginning to see the value of that as well and we'll closely monitor that. Our goal is always to have our patients receive the services where they need them, but also to make sure that we're maximizing so that they can come to a primary location additionally with the specialty units that are there as well. So you can see there's a significant amount of services that are available to the patients. And I think that helps with the resident program as well because they also have the partnership with the other residency programs that are occurring, and it offers that population health that a team-based care approach.
2:21 PMThat's fabulous. thank you.
Any other questions? I have a couple of questions. I'm just making some quick notes here. First of all, I do want to note that y'all expect a growth rate of just above 6% over the coming years. I only remark that because that was a number that most of the institutional columns, local governmental institutions were working with before the 3. 5% revenue cap. I am grateful that you all were not put in the cross hairs of that 3. 5. But I do want to recognize that it wasn't a crazy notion that all of the local governmental entities had an expectation of a 6% growth rate given that we have overlapping and sometimes identical constituencies. So i'm very grateful that y'all were not painted with that brush. So there's that. I want to also remark that the organization, central health has an organization that's been really nimble in seizing to whatever extent that you can given your capacity the various changes in policy that make it possible for us to serve our community in a state that has rejected medicaid. So this is a tool that is so important to us and I very, very much appreciate your nimbleness and willingness to look outside the box and take some calculated risks. I very much appreciate that. Third, on the question of sendero, i'm glad that it is currently, this current snapshot is good. I do want to remain vigilant, however, that sendero is an insurance company and it's only one of the insurers in the marketplace. It is cost competitive in the marketplace and although central health, you know, the property taxing entity has assisted it with a subsidy, its price point is not significantly different from the other marketplace insurers. Just doing a quick back of the envelope calculation, there are three other in insurers in the marketplace and the range of policies that are available for an individual, you know, a single parent head of household making less than $30,000 a year, it's pretty much the same price point whether it's oscar sendero, blue cross, blue shield, or am better.
2:24 PMWithin a hundred dollars a month, yes.
The price range is essentially it's, you know, between 7 and $800 nor that individual.
Depends which kind of plans they pick.
Sendero has a much anyway other he span to pick. Actually oscar has the widen.
It's not widest, it's different variations.
My point is while sendero is essentially a product of central health because of the subsidy, I do want to remark that it is one of only -- one of several insurers in the marketplace which sendero was created, we anticipated that there would be no insurers that would handle the population. So I just want to be careful about that. Insurance is a risk pool game. And when you are looking at a risk pool game -- I shouldn't say game, a risk pool enterprise, the larger your client population, the lower your risk. And the more diverse your client population, the lower your risk. Sendero has a very small client population with a -- an an acuity that slants towards the more acute patient. That is concerning just from a business model standpoint long term. It's currently stable and i'm very happy with that.
2:26 PMThank you for highlighting those issues and duly noted.
Let's keep an eye on it. for right now it's -- it's an appropriate investment. But I just remark that the probabilities if you -- if you play poker, the probabilities are not great under that scenario.
Do any of the other insurers get a premium subsidy from central health?
I didn't think they did. none of the other aca providers are getting a subsidy that allows really poor people to be able to afford this insurance like sendero is.
Thank you.
They are -- the -- but what i'm saying is if you go on health care. Gov and you put in a profile, put in any profile you want for somebody who is lower income, it will give you the various insurance companies that you could move off of m. A. P. Into. And sendero is only one of them. And it is not less expensive or more expensive than the other three.
2:27 PMBut there's a premium subsidy provided to the low-income people.
Not to the low-income person, it's provided to sendero.
And you make it available to your low-income customers, clients.
Mary smith who is purchasing the policy is paying -- what i'm saying is mary smith will be paying the premium and the premiums are competitive.
But don't you use that subsidy to off set the premium cost for the individual who is buying the insurance through sendero?
Correct. but just to separate those members -- for all our members, we're pretty happy that the plans are fairly competitive in prices. We've always tried to be the first or second-cheapest and we still are that for some of the lowest-cost plans. What happens is that is a savings that goes directly to the member. So every person of the same poverty level and age gets the same subsidy. They're allowed to pick a plan. They pay the difference, that remaining 50 to $75 per month. On the chap program, wealth central health funds it so make sure they can stay enrolled.
2:28 PMOtherwise a sendero plan would be more expensive than its competitors.
Is that accurate?
Let me try it this way. I put in a 50-year-old single mother with an income of $24,000 with one dependent, both of whom are medicaid-eligible. What comes out in a market comparison is that for oscar, you could get a premium rate depending on the plan between $5 $586 and $807. According to this, for sendero it would be between 765 and 858. Blue cross, $842 and $873. And for ambetter, $845.
2:29 PMFor the silver plans, yeah, that sounds approximately correct.
Those are the ranges, whether it was a silver, bronze, gold plan or whatever. Those are the ranges.
So if sendero gets in trouble, on this particular page, upcoming changes to healthcare financing, is that your fallback on trying to improve the care for indigents?
2:30 PMWell, I think --
I'm sorry, commissioner, could you ask your question again?
If sendero fails and they can't get on there, this particular page talks about upcoming changes to healthcare financing. And you talk about the ongoing negotiations with seaton under a payment model for hospital services. Is this what will be the backup plan in case sendero fails, for indigents?
This by default would be one piece of a backup plan. And first, if sendero were to be -- found to be a financially hazardous condition and that triggers all the regulatory actions to then shut the company down, there would have to be a concerted effort to transfer individuals to another plan who currently purchase on the aca marketplace. But then for those individuals that are at or below 200% of federal poverty level, we would reach out. Through our healthcare system that we have funding here, those individuals would have the opportunity to enroll in m. A. P. Or m. A. P. Basic. Or if they wanted to cobble together the means to try to buy insurance on the open market, they could. I don't want to represent this as the fallback plan should sendero fail. It's part of a much larger infrastructure that would have to be in place to help those people transition their care.
2:31 PMIt kind of sounds like we're going to leave them on their own.
No, ma'am. that's why I say it would be a concerted effort to help those individuals transition to care. We've already had these discussions internally. What were to happen if that were the case. There would be a significant amount of outreach effort, not just putting up a website, but person to person outreach to make sure that we were contacting individuals and explaining here's what's going to happen, here's what your options are come open enrollment time. If you look at the effort we undertook to move the m. A. P. Patients to sendero ideal care, it would be something like that plus. I've seen it before. My experience as a former insurance regulator, where companies did not do that. And that would not be the central health way. That's not the way we would treat people. We would work to make this as seamless a transition as possible, including after they transition make sure that their continuum of care is taken care of.
2:32 PMIt sounds like to me if we put more people on the sendero plan, then you're eligible to draw down some funds to complement the services of sendero, correct? If you go through to any other plan, would you be able to draw down any funds?
2:33 PMNo. because sendero is part of the enterprise, no, we would not. The strength of the enterprise --
Sendero to try to make it work. We use the federal funds to offset the risk associated with that. We wouldn't get that deal with another insurance company.
That's what I would think. So, I think we need to continue on toward the goal of putting more people on sendero.
Other questions? yes.
Could I have 15 seconds? I wanted to address a comment Commissioner Daugherty had. We did partner with lone star circle of care for a clinic in jonestown. It's been completely remodeled. And my understanding is they're providing services seven days a week. So i'm sorry, I tried to squeeze in and we jumped to another question. I just wanted to come back and mention that. Thank you.
2:34 PMThank you for that. and co clarifying, those were all bronze plans. None of the ones I mentioned were silver. The ones between 500 and the upper end of 800.
I think you're saying sendero was the second-lowest? I don't see it.
Sendero was the second-lowest and in the upper limb they're all on -- limit they're on par at the upper end of 800.
Our goal is to remain competitive. Honestly, the main goal is just increasing overall access, primarily for central health's people, which is the uninsured. So as long as we can be stable enough to make -- to offer a responsible opportunity for them, you know, we'll be here. That's the goal more than, you know, being -- i'd love to be able to say we had enough capital to offer everybody $100 cheaper insurance. That's not realistic. It's more just this idea of this balance a between central health and sendero. And to Commissioner Gomez's point, it is not in our forecast that we will be coming to central health for capital. That's not the design, so.
2:35 PMAll right. that completes our update. We really appreciate --
Thank you, commissioners, judge, we appreciate the time.
To smal -- Commissioner Daugherty's point, healthcare in the united states is more complicated than it should be. We appreciate your expertise in unraveling this and getting the best benefit for travis county constituents in need of healthcare. Thanks.
Thank you, members.
Thank you.
Thank you.
Out of here?

2:35 PMI would like to get folks out of here, but there were a lot of things going on. So, let's take agenda item number -- we've got a number of things. I'm sorry, Commissioner Daugherty.
2:36 PMNo, that's --
Agenda item number 8, which you pulled from consent. Agenda item eight is to consider and take appropriate action on routine personnel actions and nonroutine personnel actions. You had questions?
Yeah. just to comment, is carlos still here? Yeah, I think he left. My only point on this was on b, chief deputy number 5. You know, obviously we put everybody on 66 a few weeks ago.