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Title: Ron J. Anderson, MD, MACP,


1
Infrastructure Stresses and Strains in Texas
The Case for Regionalization
  • Ron J. Anderson, MD, MACP,
  • Parkland Health Hospital System
  • Dallas, Texas USA

2
More Texans Live in Poverty Then in the US as a
Whole
People Living in Poverty, 3-Year Average, 2005
to 2007
Poverty is defined in 2007 as annual income
under 21,027 for family of four)
  • Only 7 statesAlabama, Arkansas, Kentucky,
    Louisiana, Mississippi, New Mexico and, West
    Virginiahave higher poverty rates than Texas

Source US Census Bureau. Income, Earnings and
Poverty Data from the 2007 Community Survey.
Accessed May 4, 2009. http//www.census.gov/prod/2
008pubs/acs-09.pdf
3
Minorities, Other Than Asians, Are More Likely to
Live in Poverty
  • Fewer disparities between Texas and the US as a
    whole, but Hispanics of any race are poorer in
    Texas

Source US Census Bureau. Income, Earnings and
Poverty Data from the 2007 Community Survey.
Accessed May 4, 2009. http//www.census.gov/prod/2
008pubs/acs-09.pdf
4
Only 12 States Have Median Incomes Lower Than
Texas
  • Median income, 2007
  • US 50,740
  • Texas 47,548
  • Demographic changes threatened to increase this
    disparity, even before the current recession
    began, according to a 2000 report from Texas
    AMs Center for Demographic and Socioeconomic
    Research and Education

Sources US Census Bureau Tables from website and
Murdock, et. al. 2002. Center for Demographic
and Socioeconomic Research and Education. Texas
AM University, 2000. A Summary of the Texas
Challenge in the 21st Century Implications of
Population Change for the Future of Texas.
http//txsdc.utsa.edu/download/pdf/TxChall2002Summ
ary.pdf
5
Average household income in Texas could decrease
from 5,000 to 6,500 from 2000 to 2040
Assumes net migration of ½ or equal to 1990-2000
Source Murdock, et. al. 2002. Center for
Demographic and Socioeconomic Research and
Education. Texas AM University, 2000. A Summary
of the Texas Challenge in the 21st Century
Implications of Population Change for the Future
of Texas. http//txsdc.utsa.edu/download/pdf/TxCha
ll2002Summary.pdf
6
More Households Will Earn Less
Source Murdock, et. al. 2002. Center for
Demographic and Socioeconomic Research and
Education. Texas AM University, 2000. A Summary
of the Texas Challenge in the 21st Century
Implications of Population Change for the Future
of Texas. http//txsdc.utsa.edu/download/pdf/TxCha
ll2002Summary.pdf
7
If Current Trends Continue, Hispanics and Blacks
Will Earn Less Than Other Groups
Median Household Income in Texas in 1999 by
Race/Ethnicity of Householder
Source Murdock, et. al. 2002. Center for
Demographic and Socioeconomic Research and
Education. Texas AM University, 2000. A Summary
of the Texas Challenge in the 21st Century
Implications of Population Change for the Future
of Texas. http//txsdc.utsa.edu/download/pdf/TxCha
ll2002Summary.pdf
8
Historically, Texas Has a Higher Percentage of
Uninsured than the US as a Whole
Sources US Census Bureau Historical Tables from
website
9
Texas Has More Uninsured Than Any Other State
Three-Year Average percentage of People Without
Health Insurance Coverage by State 2005 to 2007
Source US Census Bureau. Income, Poverty and
Health Insurance Coverage in the United States
2007. Accessed May 4, 2009. http//www.census.gov/
prod/2008pubs/p60-235.pdf
10
Before the Recession Began, Higher Numbers of
Uninsured Were Projected
  • Recession-related job loss will push these
    numbers even higher, at least in the short term,
    since 59 of insured American were covered by an
    employment-based program in 2007.

Sources US Census Bureau Historical Tables from
website, Income, Poverty and Health Insurance
Coverage in the United States 2007 and Gilmer
and Kronick. 2003. Its the Premiums, Stupid
Projections of the Uninsured through 2013, Health
Affairs Web Exclusive. April 15, 2005
11
Cost of Health Insurance Is Rising Faster than
Inflation and Income
12
If market forces could solve health cares
problems, they would have done so by now.
13
Situation Has Worsened
  • Projections Indicated Situation Would Worsen
    Before Current Recession Began
  • Average household income in Texas may decline due
    to increase in percent of population engaged in
    lower-paying activities
  • Percentage of uninsured likely to rise,
    especially as unemployment rises
  • Cost of health care and health insurance likely
    to increase

14
Parkland Fills the Gaps for Dallas County
4 of 10 HIV/AIDS patients treated here
1 in 4 trauma cases go here 4 in 10 for major
trauma
More than half the countys doctors train here
More than 1 in 4 residents lack insurance and
are likely to seek care here
More than 3 of 10 babies born here
Source Parkland Health Hospital System, 8/2008
15
Parkland Serves a Predominately Minority
Population
Inpatients
Outpatients
Source Parkland Health Hospital System, 8/2008
16
Parkland Remains Areas Busiest Hospital System
1Observation days increased due to chest pain and
abdominal trauma protocols, reducing admissions
by over 2,000. 2WISH visits included in
Outpatient totals
Source PHHS Annual Reports
17
Community Oriented Primary Care
18
COPC Health Centers Clinics, 2009
Extend into Non-traditional Settings
  • 780-bed hospital
  • 11 Health Centers
  • 8 Womens Clinics
  • 11 Youth/Family Centers
  • 4 mobile vans
  • Senior Outreach Program
  • Partnership with Dallas Independent School
    District and MetroCare (MHMR)

Source Parkland Health Hospital System, 8/2008
19
Areas Throughout Dallas County Are Considered Low
Income
80 of Median HH Income (Low Income) 50 of
Median HH Income (Very Low Income) 30 of
Median HH Income (Extremely Low Income) Greater
than 80 of Median HH Income
Source 2000 Census definitions of poverty by
Census Bureau personnel, July 2003
20
Suburban Poverty Is Increasing
Source Brookings Institute. 12/2006. Two Steps
Back City and Suburban Poverty Trends 1999 to
2005. http//www.brookings.edu/reports/2006/12pove
rty_berube.aspx Accessed 1/29/08.
21
Relative Need in Dallas County A Historic
Comparison
  • The three maps below present the evolution of
    relative need in Dallas County over the twenty
    year history of the COPCs.
  • The current system of COPC health centers is
    presented on the 2007 model for reference.

1992
1987
21
22
An Updated Need Assessment
  • Parkland has adopted four new tools/information
    sources since the original need assessment was
    designed.
  • The Community Need Index (CNI) is a product of
    Thompson-Reuters (previously Solicient)
  • Aggregates five socioeconomic indicators known to
    contribute to health disparity income,
    culture/language, education, housing status and
    insurance coverage.
  • Applied at the zip code level to produce a score
    ranging from 1.0 (low need) to 5.0 (high need).
  • Residents with the highest CNI scores twice as
    likely to experience preventable hospitalization
    for manageable conditions.
  • The Prevention Quality Indicator (PQI) index is a
    product of Agency for Health Research and Quality
    (AHRQ).
  • 13 PQIs for adults and 5 for children that
    measure rates of inappropriate hospital
    admissions
  • Index designed for adults and one designed for
    pediatrics.
  • Preventable hospitalizations are expensive

23
COPC Health Centers and Service Areas
  • The need assessment includes those centers that
    serve as medical homes.
  • Included are the nine Health Centers,
    School-based Youth and Family Clinics and the
    HOMES program.
  • Excluded are the ACC and EPO centers.
  • The Health Center primary service areas are drawn
    in black outline.
  • The Health Centers provide good coverage of the
    higher CNI zip codes.

COPC Health Centers (Pediatric Only) Other low
income providers
24
Three Views of Need / Opportunity
  • The findings from the evaluation methods are
    presented below.
  • The three zones of need/opportunity that are
    consistent in each methods results are circled
    on each of the maps.
  • Several zones of need/opportunity identified by
    one or two of the methods are also noted.

CNI and PQI Avoidable Inpatient Admissions
PCHP MembersAssigned to Other Providers
Avoidable ED Visits
25
Need Assessment Conclusions
  • Updated need assessment methodologies support and
    confirm the earlier assessments and the existing
    health center placements.
  • The market demographics have changed through
    gentrification, poverty is expanding out from the
    urban core along the major highways into the
    suburban markets.
  • The COPC sites have demonstrated that access to
    primary care does reduce preventable inpatient
    admissions and avoidable emergency department
    visits.
  • Significant areas of need for primary care still
    exist.
  • Further COPC system development should consider
    the following
  • Responsiveness to current need and projected
    demographic shifts,
  • Capacity and capability of existing sites,
  • Use of models adapted to the needs of specific
    sites,
  • Plans of other county health care systems and
    providers, and
  • Comprehensive coverage of Dallas County
    (especially post-universal coverage.

26
Mammography
  • Cancer Prevention and Intervention Program
  • Provides screening mammograms, breast cancer
    education, and case management services to
    medically-under served women in Dallas County
  • Mobile unit visits COPC health centers and
    community health fairs
  • New mammography center planned

27
HOMES Homeless Outreach Medical Services
  • Serves 28 homeless shelters
  • Mobile medical record

28
Dallas Healthy Start
  • Infant mortality for 2 target areas, Southeast
    and West Dallas, declined from 11.9 per 1,000
    births in 1990 to 6.7 in 1996

Parkland Birth Outcomes With and Without Prenatal
Care, per 1,000 live births
29
Parklands Neonatal Mortality Rate Does Not
Follow Texas and US Trends

When adjusted for severity, Parklands rate for
white women is better than the national average.
PHHS gets many referrals of high-risk women.
Source PHHS data, 1999-2001 Texas Bureau of
Vital Statistics, 2001 US Bureau of Vital
Statistics 2000. Latest available for all.
30
Relationship Between Prenatal Care and Preterm
Births
31
Dallas County Jail Health
  • Gifted to us by County Commissioners
  • No additional funding
  • Use as public health opportunity to find ways to
    decrease
  • Tuberculosis
  • Sexually transmitted diseases
  • Mental health-related admissions to jail
  • Each day, 1,100 to 1,300 of over 7,000 inmates
    have mental health-related diagnoses
  • Current cost is 34 million/year

32
Other Community Outreach Initiatives
  • Hogg Commission grant to COPC to provide mental
    health care integrated into the primary care
    setting
  • Community Health Improvement, Measurement and
    Evaluation System (CHIMES)
  • Center for Clinical Innovation and Research
  • Next
  • Institute for Community Medicine and Health
  • Research, Professional Education (professional),
    community health promotion and improvement,
    outcomes
  • Regional Health Information Organization

33
Integration of Insurance/Assurance Through the
Community Health Plan
Parkland HMOParkland Community Health Plan, Inc.
Platform for insurance for the working poor
  • Under this model, patients
  • Remain in the same health plan
  • Keep the same primary care doctor
  • Receive services at the same COPC Health Center
    or primary care area
  • Retain the same Medical Record
  • Have their information retained in the same data
    base
  • Integration of subspecialty care and care
    management
  • Have their cost of care funded by a combination
    of Medicaid, Disproportionate Share, or ad
    valorem taxes

34
Enrollment in PCHP Healthplus Programs,
September, 2007
Children 0-18
Perinate
116,230
77,000
24,593
5,653
18,940
Healthfirst
KIDSfirst
Healthplus
(40 market share w/o perinate, 52 market
share with perinate)
(51 market share)
Source Parkland Community Health Plan,
September, 2007.
35
PCHP Outcomes
  • Improved emergency room utilization through the
    establishment of a medical home and through
    management of outliers.
  • Lower percentage of low birth weight births than
    the community average.This has extended to beyond
    the Parkland system to the community based
    providers.
  • Asthma disease management program has with 2,000
    children enrolled is a public/private partnership
    for disease management. The private company is
    at 100 risk for improved outcomes.

36
What Is the Safety Net?
  • Providers of last resort for more than 5 million
    uninsured Texans
  • Often provide services that will never be
    available in some areas of Texas, for example
  • High fixed-cost services, like trauma, burn care,
    neonatal and pediatric intensive care
  • High-cost, low-volume services like subspecialty
    referral and tertiary care
  • Usually crucial to emergency preparedness and
    linked to public health infrastructure
  • Funding vulnerable to changing economic
    conditions and fluctuating public support

Source Safety Net Monitoring Initiative.
http//www.ahcpr.gov/data/safetynet/netfact.htm
37
In 2000, Safety Net Described as Intact but
Endangered
  • 2000 Institute of Medicine (IOM) report the
    health care safety netthe Nation's "system" of
    providing health care to low-income and other
    vulnerable populationsis "intact but
    endangered."
  • Precarious financial situation of many
    institutions that provide care to Medicaid,
    uninsured, and other vulnerable patients.
  • Changing financial, economic, and social
    environment in which these institutions operate.
  • Highly localized, "patchwork" structure of the
    safety net.

Source Safety Net Monitoring Initiative.
http//www.ahcpr.gov/data/safetynet/netfact.htm
38
In 2005, Safety Net Described as Threadbare
Its Strength Overestimated by the General Public
  • 2005 Kaiser Commission on Medicaid and the
    Uninsured report the health care safety net is
    threadbare."
  • Demands on system too great
  • System fragmented, leaving patients to bounce
    from one facility or program to the next to find
    medications, medical equipment, lab and x-ray
    services, rehabilitation services, specialty care
    and even hospital care
  • Over a third of uninsured report not getting
    needed care, a rate 3 times that of insured
  • At least 18,000 Americans die prematurely each
    year due to lack of health care coverage

Source Kaiser Commission on Medicaid and the
Uninsured. 2005. Threadbare Holes in Americas
Health Care Safety Net. Accessed May 5, 2009.
http//www.kff.org/uninsured/upload/Threadbare-Hol
es-in-America-s-Health-Care-Safety-Net-report.pdf
39
Texas Is a Mix of Rural and Urban
  • 132 counties are rural
  • 122 counties are urban
  • 77 are part of metropolitan statistical areas
  • 45 are considered micropolitan (urban area with
    population of 10 to 50 thousand plus surrounding
    counties linked by community ties
  • 87 of Texans live in urban areas
  • Urban areas are clustered, with most of the state
    being rural

Source Rural Policy Research Institute.
Demographic and Economic Profile Texas Updated
April 2006. Accessed May 7, 2009.
http//www.rupri.org/Forms/Texas.pdf
40
Most of Texas Is Medically Underserved
  • Index of 4 variables
  • Ratio of primary care physicians per 1,000
    population
  • Infant mortality rate
  • Percent of population below poverty level
  • Percent of population over 65

Source Rural Policy Research Institute.
Demographic and Economic Profile Texas Updated
April 2006. Accessed May 7, 2009.
http//www.rupri.org/Forms/Texas.pdf
41
Most of Texas Needs More Healthcare Providers
  • Shortages of 1 or more
  • Primary care providers
  • Dental providers
  • Mental health providers

42
Defining the Urban Safety Net in Texas
  • Initial attempts focused on provider
    characteristics like open-door policies and
    services to vulnerable populations
  • More recently, focus has shifted to more
    quantifiable factors
  • Uncompensated care expense
  • Adjusted uncompensated care market share
  • Specialty service lines like neonatal and
    pediatric ICU, burn care and trauma
  • Tier 1 1st decile ranking uncompensated care,
    all 4 services, 3 years of data
  • Tier 2 2nd decile or higher ranking
    uncompensated care, some but not all services gt3
    years of data
  • Tier 3 uncompensated care community level
    services
  • Undesignated dont meet Safety Net criteria

Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
43
Hospital Distribution Using Safety Net
Designation Formula
Short-stay, General Medical/Surgical Texas
Hospitals from MSA 193
Undesignated Hospitals 140
Designated Hospitals 53
Non-Safety Net Hospitals 140
Tier 1 Safety Net Hospitals 19
Tier 2 Safety Net Hospitals 19
Tier 3 Safety Net Hospitals 15
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
44
Hospital Distribution by Ownership Safety Net
Designation
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
45
ER Visits Admissions by Safety Net Designation
Parkland in 2005 143,601
38,793
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
46
Total Amount of Uncompensated Care per Year by
Safety Net Status in Millions
Dollars in Millions
Safety Net Status ( of hospitals)
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
47
Total Margin by Safety Net Status per Year
Total Margin
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
48
Functional Capacity by Tier by Year
Functional Capacity
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
49
Age of Plant by Safety Net Status Over 3 Years
Age of plant
Sources Brett D. Stauffer, MD Ruben
Amarsingham, MD Sue Pickens, M.Ed Ron J.
Anderson, MD. "Comparing the financial condition
of Texas hospitals using a novel definition for
the safety net." Texas Medicine, Vol. 104,
Number 8. August, 2008, pp55-62. and R
Amarasingham, S Pickens, RJ Anderson, "County
hospitals and regional medical care in Texas an
analysis of out-of-county costs." Texas
Medicine, June 2004, pp. 56-59.
50
Special Challenges to Tier One and Two Regional
Hospitals
  • Must maintain utility-like or value-added
    services requiring high stand-ready costs
  • Must bear higher costs of caring for high volumes
    of low-income patients
  • Must bear higher drug costs associated with
    special populations like HIV/AIDS patients
  • Most must absorb cost of medical education,
    clinical research, new procedure development
  • Must bear cost of emergency preparedness

Difficult to compete on price in the marketplace
51
Parkland as an Urban Example of the Need for
Regionalization
  • Began as a city effort
  • Joined by county
  • Became a hospital district to increase tax
    fairness
  • Now sees increasing patient volumes from
    contiguous counties and other parts of the state
  • Current system is not sustainable due to
    demographic pressures and changing tax bases
  • Doughnut effect
  • Poverty moving to suburbs
  • More-rural counties accessing Safety Net services

52
Evolution of a Health System
1913
?
1954
2014
1982
53
Parklands trauma volume is twice regional and
national averages, 2003
27 increase
Parkland
Source Texas Trauma Registry/ Regional average
includes Parkland data for FY 2003 Source
National Trauma Data Bank, Report 2004 National
Average is a 5 year average.
54
Parkland Incurs Substantial Costs for Trauma Care
Costs are defined as charges to the patient of
patients are for patients that have charges
available
55
Parklands Out-of-County Trauma Patient Mix by
County (CY 2006)
  • 60 come from contiguous counties
  • 14 come from next tier contiguous counties
    (Hunt, Henderson, Navarro, Cooke, Fannin,
    Grayson,
  • 25 come from Texas counties, out of state or
    outside the US
  • 1 are unidentified

Denton
Collin
Hunt
172 12.6
208 15.2
101 7.4
Rockwall
62 1.8
Tarrant
Dallas
Kaufman
163 11.9
66 4.8
Ellis
88 6.4
56
Parklands Payer Mix for Out-of-County Trauma
Patients, 2006
Inpatients Outpatients
Source TII, download 2006 from Robyn Manning
57
Parklands Burn Center Serves a Large Area.
Traditional 88,000 square mile catchment area
  • Closing of Shriners in Galveston has caused a
    ripple effect here
  • tripled our catchment area for pediatrics
  • Resulted in the need to decline transfers from
    within our usual catchment area because beds are
    filled by patients from Galveston

58
Burn Center Admissions Have Increased Overall
Due, In Part, to Galveston Closing
14
30
Projected admission numbers obtained using data
from Jan 09 thru April 09
Source Parkland internal data, May 2009.
59
Parklands Out-of-County Burn Patient Mix by
County (CY 2006)
  • 54.2 come from contiguous counties
  • 45.8 come from other Texas counties, out of
    state or outside the US

Denton
Collin
Hunt
45 7.2
53 8.5
20 3.2
Rockwall
0 0
Tarrant
Dallas
Kaufman
183 29.3
16 3.2
Ellis
22 3.5
Source TII, download 2006 from Robyn Manning
60
Parklands Payer Mix for Out-of-County Burn
Patients (FY 2006)
Inpatients Outpatients
Source TII, download 2006 from Robyn Manning
61
Parkland Trauma Revenue from Texas Bad Drivers
Bill
62
NorthSTAR
Behavioral health and substance abuse services
for over 355,000 clients in 7 counties (Q3 2008)
Source Texas Department of State Health
Services. NorthSTAR Data Book Q3 2008.
http//www.dshs.state.tx.us/mhprograms/northstarda
tabase.shtm Accessed 11/12/2008.
63
NorthSTAR
  • Blended funding - State and local agencies
    contribute wrap-around funds for a person's
    treatment. No longer does a person have to mine
    the various agencies and departments to receive
    services.
  • Integrated services - Mental health and chemical
    dependency treatment are coordinated under
    behavioral health, allowing integrated treatment
    in a single system of care.
  • Care management - Individuals receive the proper
    amount of cost-efficient care.
  • Data-based decision support - A modern data
    warehouse and decision support software is used
    to evaluate and manage the system of care.
  • Behavioral Health Organization - Services are
    provided via a fully capitated contract with a
    licensed behavioral health organization.
  • NorthSTAR Quality Monitoring Strategies

Source Texas Department of State Health
Services. http//www.dshs.state.tx.us/mhprograms/N
orthStarhomepage.shtm Accessed 11/12/2008.
64
NorthSTAR Volumes
  • Types of Services
  • Rehab, MH Outpatient, Case Management and ACT
    services
  • Community Inpatient
  • ER/Observation Room Services
  • Medication Services
  • CD Residential and Inpatient
  • CD Non-residential and Outpatient
  • Other Community Services

Source Texas Department of State Health
Services. NorthSTAR Data Book Q3 2008.
http//www.dshs.state.tx.us/mhprograms/NorthStarho
mepage.shtm Accessed 11/12/2008.
65
NorthSTAR Volumes by County
Source Texas Department of State Health
Services. NorthSTAR Data Book Q3 2008.
http//www.dshs.state.tx.us/mhprograms/NorthStarho
mepage.shtm and Texas State Library and Archives
Commission. http//www.tsl.state.tx.us/ref/abouttx
/population.html Accessed 11/12/2008.
66
Dallas County Has Worked to Overcome Many
Challenges
  • Support for Parkland and its programs has been
    strong for decades as shown by support for
    hospital district taxes and bonds
  • 2008 bond proposal for new facility passed 82
    for, 18 against, an overwhelming majority

67
Master Facility Plan Revised Total Project
On March 14, 2008, the Blue Ribbon Panel
recommended that Parkland pursue completion of
the total master facility plan project
(hospitals, clinics and office buildings and
parking) with estimated total project costs of
1,371 million. On June 24, 2008, the DCHD Board
of Managers approved a revised projectwhich
meets the requirements of the Blue Ribbon Panel
recommendationcalling for new campus on the
north side of Harry Hines Blvd. by using a single
efficient hospital, moving space to lowest cost
facilities, maximizing surface parking, which
reduced estimated total project costs by 100
million to 1,271 million.
Clinics
Offices
Parking
Hospital
Lofland Parking- demo
Parking
Parking
Harry Hines Blvd.
Present Hospital
Present Clinics
ER Parking- sold
Motor St. Parking
Amelia Ct. Parking
67
68
Revised Total Project Scope and Costs
New Replacement Hospital 862 adult beds,
1.68 million square feet, open April 2014
1,053 million (83) Adult bed
complement Completed Shelled
Total Current 675 0
675 Proposed 816 46
862 Capacity Increase 141 (21)
46 187 (28) Clinic Buildings
387,000 square feet, open April 2014
105 million ( 8) Office Buildings 269,000
square feet, open January 2011 50
million ( 4) Parking (2,035 new garage spaces,
2,800 new surface spaces) 42 million (
3) Net Land Purchases, Sales, Demolition,
etc. 21 million ( 2) Total
Project Costs 1,271 million plus 60 beds
for an expanded PMR service and 46 beds for
enhanced inpatient services if performance can
provide needed revenue equals the 968 beds per
the PwC/Blue Ribbon Panel studylocation which is
yet determined includes 117 newborn and 96 NNICU
beds. also need 4-5 additional COPC health
centers and 2 subspecialty clinics
68
69
Proposed Project Financing
G. O. Bond Proceeds Series 2009
534 million Series 2011 or
2012 163
million Revenue Bond Proceeds
42 million Philanthropy
150 million Interest on
Bond Proceeds 32
million Future Cash (Note 1)
100 million Cash Reserves
250 million Total
Project Costs 1,271
million G. O. Bond Size 705
million Revenue Bond Size 42
million Total Bonds 747 million G. O.
Bond Tax Support 2.5
cents Tax on Median Homeowner (Note 2) 46.24
Note 1 - Future cash of 100 million in excess of
operating cash reserves would be required to be
transferred to the project fund prior to
beginning construction on the 105 million clinic
buildings. Note 2- Includes operations tax
support of 1 cent beginning in 2014 median home
value 132,000. 83 million raised to date
69
70
Regional Planning Funding Critical
We must address the artificial boundaries that
affect our ability to improve public health
geographical, political, economic.
  • Disaster preparedness (hurricanes, tornados,
    etc.)
  • Terrorism (including biological agents)
  • Pandemics (Influenza)
  • Indigent care
  • Mental Health
  • Regionalization for tertiary and quaternary care
  • Trauma/burn
  • Cancer care
  • High-risk perinatal
  • Transplantation

71
Regionalization Could Provide Answers
Existing Texas Health Department Regions could
provide initial organizational structure
72
Regionalization Would Allow Fairer Distribution
of the Tax Burden
Many counties have neither public hospitals nor
hospital districts.
73
Existing Medical Schools Could Serve as Important
Resources
74
Creating a Win-Win for Dallas County and Its
Neighbors
  • Expand regional UPL concept
  • Brought Dallas County area hospitals 130 million
    in new federal matching for Parkland taxes
  • Participating counties with hospitals owned by
    Baylor, THR and HCA systems
  • These dollars could be used to re-invest in
    regional infrastructure as well as pay for
    tertiary care support

75
Pending Legislation on Regionalization
  • SB2476
  • North Texas Trauma and Burn Authority Act
  • Sen. Bob Deuell (R)
  • HB515
  • Expansion of the Boundaries of the Dallas County
    Hospital District
  • Rep. Allen Vaught (D)

76
SB2476North Texas Trauma and Burn Authority Act
  • Purposes
  • Development, implementation, management, and
    supervision of an integrated and cohesive system
    for improved Level I and Level II trauma and burn
    care in the 19 counties of northern Texas that
    comprise Trauma Service Area E
  • Creation of regional trauma and burn authorities
    to develop and implement plans to design, modify,
    and expand infrastructure to support trauma care
    facilities
  • Reduction of burdens and demands on the limited
    funds available for trauma care and to increase
    the effectiveness and efficiency of expenditures
    for trauma care and
  • Seek funding from the federal government under
    the American Recovery and Reinvestment Act of
    2009 (Pub. L. No. 111-5) and from other funding
    sources.

Source Texas Legislature Online. Accessed May 4,
2009. http//www.legis.state.tx.us/
77
HB515Expansion of the Boundaries of the Dallas
County Hospital District
  • Contiguous counties may file a petition
    requesting inclusion in the District
  • Commissioners Court may pursue issue of annexing
    territory to the District
  • Annexation must be approved by Dallas County
    voters and voters in territory to be annexed
  • If territory is in another hospital district, the
    election will dissolve the other district in that
    territory
  • Dallas County Commissioners appoint an advisory
    committee to represent the interests of the
    annexed territory

Source Texas Legislature Online. Accessed May 4,
2009. http//www.legis.state.tx.us/
78
  • You cannot escape
  • the responsibility of tomorrow
  • by evading it today.
  • Abraham Lincoln
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