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HomeMy WebLinkAboutMinutes 05-10-2011 APPROVED 9/8/2011 MINUTES ORANGE COUNTY BOARD OF COMMISSIONERS BUDGET WORK SESSION May 10, 2011 7:OOpm The Orange County Board of Commissioners for a Work Session on Tuesday, May 10, 2011 at 7:00 p.m. at the Link Government Services Center in Hillsborough, N.C. COUNTY COMMISSIONERS PRESENT: Chair Bernadette Pelissier and Commissioners Alice M. Gordon, Barry Jacobs, Pam Hemminger, Earl McKee and Steve Yuhasz COUNTY COMMISSIONERS ABSENT: Valerie Foushee COUNTY ATTORNEY PRESENT: John Roberts COUNTY STAFF PRESENT: County Manager Frank Clifton and Clerk to the Board Donna S. Baker (All other staff inembers will be identified appropriately below) Chair Pelissier said that Commissioner Foushee was absent because she had a death in the family. 1. Report to the BOCC: Phase One Assessment of the Current Fire, Rescue, and Emerqency Services Commissioner Gordon asked if this was the same report they received earlier and the consultant said that there are a number of changes. Commissioner Gordon asked that the changes be highlighted. The consultant from MMA Consulting Group, Inc. made a PowerPoint presentation. Assessment of the Current Fire, Rescue and Emergency Services Delivery System Orange County, North Carolina Report Overview • Emergency Response — 2009 Fire-Rescue Agencies 10,290 • 4.7% Fires; 51.1% FR/EMS; 44.1% Other — 2009 County EMS 10,945 • Personnel — Fire — Rescue Departments —434 — County Emergency Services — 99 — South Orange Rescue Squad — 82 • Fleet — County-wide Emergency vehicles • Facilities — Twenty Stations — 98.5% County roads within 6 miles of existing Station — 97.8% County roads within 12 minute travel of Station • Finances — Fire — Rescue $ 3,382,35 — County Emergency Services $7,062,571 • Strengths — Infrastructure — Individual Agencies — Central Dispatch • Weaknesses — Data Collection — Service Delays — Radio Limitations • Opportunities — County Aiding Volunteer Agencies — Strategic Planning — Response Districts • Threats — Relationships — Economy — Questions Commissioner Gordon said that she had asked about the inclusion of service by Mebane and North Chatham the last time and they have not been added. The consultant said that North Chatham serves quite a large area and they were not successful sorting out what was in and out of the County. Commissioner Gordon said that one needs to have these numbers and this information for these agencies because there are parts of Orange County in the south and west that are served by them. She said that they need to start collecting data since Mebane and North Chatham get funding from Orange County. She wants to see these numbers. Chair Pelissier asked the County Manager to address this. Frank Clifton said that there are data issues and when there is a mix of paid and volunteer fire departments, it is hard to get consistent data. Chair Pelissier said that the data is not really usable and she suggested adding `lack of data' as another weakness. Frank Clifton suggested saying `standardization of data.' Commissioner McKee made reference to page 8 and approximately 10,000 fire department calls annually and on page 72 it states that there were 11,995 EMS calls. He asked if this was double counting because the fire departments respond to half of EMS-type calls. The consultant said that it appears that this is double counting. He said that during the BOCC meeting in March when the initial report was received, the fire chiefs requested some additional information. He asked if all of this information had been updated because South Orange Rescue still states that it has a Chief and an Assistant Chief for each division. The consultant said that he had the comments. Chair Pelissier suggested adding some caveats in the document to make it clearer about the number of calls. Commissioner Jacobs acknowledged the presence of so many fire chiefs, assistant fire chief, and EMS personnel and he said that he is sorry they are doing this in a work session since the fire chiefs wanted to have a conversation with the Board of County Commissioners. He said that there was a very good meeting of the steering committee a few weeks ago. They discussed this report and some issues were raised. One of the things that came up in that meeting was that there is not accurate data. It was also identified that the CAD software needed to be updated. There was also discussion about how people have taken this report as implied criticism of the volunteer fire departments. At this meeting, there was more of a peace about this issue. Commissioner Jacobs said that the Board needs to decide what kind of reports they want generated and which risks to manage. He wants to try and make a better system. Commissioner Hemminger said that as she read this document she realized how much the County depends on its volunteer fire departments. Frank Clifton said that the County has come to the scene of emergency services a little late as a governmental function since it has relied on the volunteers for so long. Even though the departments are called volunteer, they would not be able to function without paid staff countywide. He said that this is a universal problem in the state. He said that many of these paid staff work for various fire departments. He said that these volunteer departments are basically independent agencies and this study is basically an inventory of what the County has and is doing now. He said that he does not think that the County wants to manage independent fire department districts, but he wants to at least try and conform to some sort of standard. He said that the departments need to be flexible and so does the County. Commissioner Hemminger said that since the County cannot afford to take over this system, the County Commissioners need to become better at communicating with these departments because right now it is all over the place and there is a lack of coordination. Commissioner McKee said that he found it disturbing that the largest service provider in Orange County— Orange County EMS — had a section of about four pages. The number of personnel is higher than any of the other departments. He said that there was no breakdown on Orange County's calls, but there was a breakdown on some of the volunteer departments. There was also no equipment breakdown. He said that this seems to be only a cursory review of the County EMS as opposed to a more in-depth review of the fire departments. He personally feels that more ambulances are needed on the road, but he has no way to justify that without the data. He said that it is unfortunate that this has been done in a work session where public comment cannot be taken. He would like to have a work session with the fire departments since the fire departments are a taxing authority. Chair Pelissier said that she attended a fire chiefs meeting last week with Commissioner McKee and she echoed his suggestion of having a work session with the volunteer chiefs in the County. She suggested that EMS and others respond to these weaknesses. Commissioner Jacobs said that the only time the County Commissioners have any direct dealing with what fire departments do is when they approve their budgets. He said that one purpose of this was to give some context but also to educate the Board. He said that he is uncomfortable when people average out times for various departments because it is an average of people who live in Hurdle Mills and people who live in the rural buffer. This is not an intelligent way to measure services. He thinks that everyone is committed to promoting and protecting public safety. He said that he would like to see staff come back with comments from providers and look at what the next steps could be. He would like to see the Manager work with the appropriate entities and come back with some possible next steps and improvements to make regarding the costs. Commissioner McKee said that he realizes this report was conceived as a three-part study, but he will not be comfortable moving forward with any other part of this study until there is some discussion with the service providers regarding the weaknesses and strengths and trying to develop some sort of strategic plan. Chair Pelissier said that she would not like to move on until there is a joint session with the service providers. 2. OPC Area Proqram Update on Medicaid Waiver Expansion — Partnership Proposed with Piedmont Behavioral Health LME Assistant County Manager Gwen Harvey gave some background information. She said that the OPC Board has unanimously agreed that this should go forward and the other counties have also approved it. Judy Truitt, OPC/LME Director, summarized the information. SUBJECT: OPC Area Program Update- April 2011 PURPOSE: To receive a report on the expansion of the 1915(b)(c) Medicaid waiver & the expected impact on the mental health, developmental disabilities & substance abuse service system in Orange, Person & Chatham Counties. BACKGROUND: On March 31, 2011 the Department of Health & Human Services (DHHS) released an RFA for the expansion of the 1915(b)(c) Medicaid waiver, which will have significant impact on the organizational structure and governance of the existing system. HISTORICAL INFORMATION: House Bill 381, passed in October 2001, outlined a major transformation of the public mental health system. Guiding principles included: • Greater choice for consumers — choice was never intended to be open-ended • No wrong door for admission to services • Services provided in the local communities • Greater involvement by both consumers and the provider community • State wide standardization and accountability • Focused shift to best practice and evidence-based treatment • Separation of management oversight from the provision of service In response to the new legislation OPC initiated divestiture of service programs in December 2003 and began its transition to a Local Management Entity (LME) with responsibility for: • screening, triage & referral for consumers entering the service system; • authorization of all state and/or locally funded services; • endorsement and monitoring of a comprehensive provider network; • customer service and community planning for our three county region. In 2007 the North Carolina General Assembly passed legislation that required that LMEs have a total population of 200,000+ or cover a geographic region of six or more counties. With a total population of 227,963 OPC is the fourth smallest LME in the state. As noted above LMEs were given responsibility for management of state and locally funded services, while management of Medicaid funded services was given to Value Options, a private for-profit vendor. This remained true until April 2005 when DHHS began operating a pilot project which allowed Medicaid funded services for mental health, developmental disabilities and substance abuse treatment to be provided on a capitation basis through a 1915(b)(c) combination waiver at PBH, the LME which covers Cabarrus, Davidson, Rowan, Stanly & Union counties. This pilot project has been successful and DHHS has made the decision to move forward with statewide expansion of the 1915(b)(c) waiver. What is a 1915(b)(c) Medicaid waiver? In 1965 amendments to the Social Security Act (SSA) established the Medicaid program. Under the Medicaid program each state establishes its own eligibility standards, benefits packages, payment rates, and program administration. The Social Security Act authorizes multiple waiver and demonstration authorities which allows for flexibility at the state level. Under Section 1915 (b) of the SSA, waivers are granted which allow states to implement managed care delivery systems and restrict consumer choice of providers. These specific waivers often target individuals with mental health and substance abuse issues, although some services are available for people with intellectual/developmental disabilities (I/DD). States may choose to simultaneously operate 1915 (b) and (c) waivers. Medicaid waivers are used to improve access to and quality of services, as well as manage cost. REQUEST FOR APPLICATIONS — 1915(b)(c) Medicaid Waiver Expansion KEY POINTS: • This is the final RFA that will be issued for statewide expansion. • Full expansion is expected to be completed by January 2013. • LMEs applying to operate a waiver must have an unduplicated minimum Medicaid eligible population of 70,000 individuals 3 years and older; a total population size of 300,000 by July 2012, and a total population size of 500,000 by July 2013. [OPC = total population of 227,963; number of Medicaid eligible individuals 3 years and older is 22,372] • A single LME may apply if it meets all minimum requirements. If a single LME does not all minimum requirements it will be expected to merge with one or more other LMEs, with one entity being identified as the lead LME. • Applications must be received by May 20, 2011. • By the date of the RFA application submission, all LMEs must identify which lead LME they will partner with to perform the required Medicaid managed care and LME functions. If LMEs do not identify working partners, then DHHS will assign LME catchment areas. OPTIONS AVAILABLE TO OPC: In February 2010 OPC was approached by PBH, the LME currently operating the 1915(b)(c) pilot project, about the possibility of forming an alliance. With approval of the OPC Area Board negotiations were initiated. In June 2010 legislation was passed which restricted PBH from expanding their geographic region and limited the number of sites for expansion of the Medicaid waiver. OPC's negotiations with PBH were put on hold. Legislative support now exists for removal of the restrictions on PBH, as well as expansion of the waiver, and the OPC Area Board has authorized the Area Director to re-engage in negotiations. OPC AREA BOARD RECOMMENDATION TO BOCC: At their April 11th meeting the OPC Area Board reviewed the RFA and after extensive discussion the following motion was approved by unanimous vote. The OPC Area Board authorizes management of OPC to pursue negotiations with PBH to be identified as the lead LME to operate Medicaid funded services through a 1915 (b)(c) combo waiver for the OPC catchment area; to pursue a merger arrangement with PBH for the provision of services in the Orange, Person and Chatham counties catchment area; and to seek authorization of the Boards of Commissioners of Orange, Person & Chatham counties to proceed with negotiations with PBH towards these ends. Because Chapter 122C of the North Carolina General Statutes empowers and requires counties to determine the area authority through which they provide services, the OPC Area Board requests authorization from each county to proceed in accordance with the motion it adopted. Successful negotiations would result in the necessity at a later date of a resolution from each Board of County Commissioners to both join PBH for the provision of services and to dissolve OPC. The only action needed at this time is the Board of County Commissioners' concurrence in the negotiations recommended by the OPC Area Board. Judy Truitt said that federal law mandates that people have choice and it is not just an open door. She said that OPC will not be kicking providers out of the system. Every provider in the system will come under the Medicaid waiver and it will be an outcome-driven system where providers are matched with the needs of the community and will be held to performance standards. The system is evolving that corrects some of the steps that were taken when the reform effort began. She said that the reality is that things have changed and public mental health is no longer what it was in 1968. There is extreme pressure to change because of federal health care reform. She said that they are designing a regional presence that will be located in Concord and they will also have a local presence. She said that at the regional level will be the back office staff. Bill processing for the waiver and decisions about the waiver will be made at the regional level. She said that local management of the local center will sit at the policy level at the regional level in Concord. She said that there is also concern from the development disabilities groups because they believe that there are potential losses for consumers with developmental disabilities. The concerns have been heard and are being addressed. She does not agree with all of the concerns, but they still care about the issues. There will be a series of public forums across the region. The first public forum will be in Orange County. There is an email address where people can ask questions and answers will be posted on the Q&A page of the website. She said that there have been concerns raised across the state from some advocacy groups that if OPC participates in this waiver, then counties are going to be at risk. This is not true and the counties will be no more at risk under a managed care waiver than they currently are. The legislature has included language in the draft bill, HB 916, which makes a flat statement that counties will not be at risk for cost overrun or expenses in a managed care environment. Judy Truitt said that they are under an order to announce the partnership they will be joining by May 20th and if they do not, the Department of Human Services will make that choice and will tell them who they will join and how it will be done. She thinks that OPC will be moving forward by April or July of next year. Commissioner Yuhasz said that this allows the County to negotiate with PBH as to how this merger will be structured. Judy Truitt said that there have been concerns raised about how OPC is not contiguous with PBH. It is separated on the southern end by Randolph County. She said that she would argue that being non-contiguous incentivizes the system to make sure that there is a strong local presence. Commissioner Jacobs asked about the governmental structure of this large, multi- county entity. Judy Truitt said that under the current general statute, Boards of Commissioners appoint the representatives who sit on the area mental health board. If N. C. General Statute remains the same related to governance, then the 15 counties that would be a part of the new entity would create the board for the new entity. The statute says that the board cannot be larger than 25 or smaller than 11 members. The proposal is to change the governance type to more of the governance model of the board of the hospital. It would be a much smaller board and there would still be the opportunity for local appointment to sit on the board. This is not in place yet. Commissioner Jacobs asked about the number of counties because he only saw a few and Judy Truitt said that there are 15. Commissioner Jacobs said that this needs to be reflected in the information. He said that Orange County is the most progressive in this 15 county governance and asked why they did not try to engage a county such as Durham County. Judy Truitt said that when they began exploring options, PBH was the only entity in the State that was managing a waiver setting. She said that they did not deliberately exclude Durham, but went in the direction that was presented to them by PBH. Commissioner Jacobs requested information on the total population in OPC of the pool of clients. Judy Truitt said that the combined population of 15 counties will be 1,390,224. The Medicaid eligible population will be 193,391. The population is what most people feel is the best size for a waiver setting. 3. Employee and Retiree Health Care Coveraqe Frank Clifton said that they are not here to make a decision but for purposes of discussion. He made reference to the last page of the abstract, page 18. He said that the employee salaries and wages are about 31% of the General Fund budget. The retirees are having a large impact on the budget because of dependent coverage. He is not asking the Board to rush decisions, but health insurance costs are not going down and they need to make decisions about how to manage those costs. There are now 271 retirees, with another 80 that are eligible to retire. Interim Human Resources Director Katherine Cathey introduced Benefits Manager Diane Shepherd and Mark Browder from the consulting firm Mark III. She said that the materials show the County's recent health insurance history, a summary of benefits provided by other local governments, results from a recent employee survey, options for lowering health care costs, and a fiscal year 2010-11 budgeted costs for salary and benefits. Orange County faces increased costs in health insurance due to national increases as well as Orange County's specific situation. The increases are compounded by the fact that NCACC has given generous renewal rates over the last couple of years and the fact that Orange County provides insurance for retirees. Orange County employees receive generous benefits and have health and dental benefits that are better or equal to other jurisdictions in North Carolina. Overall, employees are very satisfied, with the exception of the County contribution to 401(k) or 457, which is not competitive. Employees are concerned with deteriorating benefits as costs increase. Based on the survey done in April, employees who do not have the dependent subsidy are in favor of seeing that disappear. The actual increase in health insurance is anticipated to be 25% or higher, so the County may have to make difficult decisions about how the costs are shared. Diane Shepherd made a PowerPoint presentation. Agenda Item #3 Preferred Provider Organization (PPO) •Preventive care is 100% covered •The employee (or dependent) pays a fee (Co-Pay) for all office visits and prescriptions •There is a deductible for services such as hospitalizations, surgeries and durable medical goods •An additional share of the cost is paid for these services (Co-Insurance) with an annual maximum Health Savings Account Hiqh Deductible Medical Plan Tax Advantaged HSA Plan •Provides coverage for current medical/pharmacy expenses and allows the option to save for future health expenses •Contributions to the HSA can be made by the Employer and/or Employee •Money deposited to the Health Savings Account is generally not taxable Health Savings Account Plan •Preventive care is 100% covered •There are no co-pays •There is co-insurance for all services before the annual out of pocket maximum is reached •All services, except covered preventive care, are subject to a deductible •Employer funds in the Health Savings Account are used for the co-insurance before the employee spends his or her own money She introduced Mark Browder, a consultant working with the County since September. Mark Browder made a PowerPoint presentation. Medical Plan PerFormance and Projections Medical Plan Renewal — Overview - The Orange County medical plan has performed poorly. - The NCACC did not charge the County the needed renewal rates (underfunded). - We anticipate a significant increase. - The Plan is out to bid and we will have the responses back to the County by May 26tn - We are asking for fully insured and self-funded responses. He went through the total claims for each year (page 6 of the PPT) The firm that the County was using decided to go out of business. - We have bid a dozen Medical Plans this renewal season. - The carriers have been ultra conservative and very inflexible - The loss of the NCACC as a Medical Plan market was negative for Counties. - The private insurance carriers have taken the position that they are not in the business of going out of business. The current expectation for renewal rates is 33%, which is not sustainable. He went through the numbers on page 11 and the renewal expectation. He explained the benefits of health savings accounts. He said that he would not recommend using a firm that does only health savings accounts. Frank Clifton said that the Board of County Commissioners has a window to review this information and there are difficult decisions to be made. Everything is set through December for the coming fiscal year, but after that, decisions will need to be made. Commissioner Gordon asked how Orange County performed poorly and Mark Browder said that the premiums that were charged did not cover the claims. This has happened in other counties too. Commissioner Jacobs said that when they are talking about change, employees start to worry about things that employees thought they had when they were hired. He wants to be clear with employees what will happen. Frank Clifton said that the issues are what the County can afford to provide. Commissioner Jacobs asked about the in-house clinic and when this would be considered. Frank Clifton said that in a self-insurance plan, there is more ability to write rules. Mark Browder said that once the insurance issue is figured out, then they will start exploring the other opportunities. Commissioner Jacobs said that he would like to see what employees would say about either increasing 401(k) or limiting the increase in the deductibles. Frank Clifton said that the reality is that the County has to do something different and it will have a negative consequence. 4. Update on Automated Aqenda Research Chief Information Officer Todd Jones summarized this item. He said that the Board's feedback has been received and is incorporated into the summary in Attachment A. There seems to be agreement that this is the format that the Board wants to use predominantly. There were differences of opinion on willingness to bring laptops to meetings versus having the equipment at the various meeting places. It would be more difficult to have equipment ready at the meetings. This is one of the pivotal issues. Frank Clifton said that hardwiring systems is better because you have to rely on wireless networking for individual laptops. Todd Jones said that there is not yet a graceful annotation package on the market now, but he is looking for something that will work. There seems to be unanimity of internet options and having the data installed locally on each machine through a flash drive or other mechanism. Todd Jones pointed out the gaps shown on Attachment B. He said that he is looking for something that would enable the County Commissioners to drop comments right on the screen associated with the items. He said that they are looking at efficiencies of the agenda preparation side when looking at this process. There will have to be training for both staff and the Board of County Commissioners. He will continue to do research of vendors, narrow it down to one or two systems, and have the vendors come and present demos to the Board. Frank Clifton said that there may still have some paper revisions of items at the meeting because of last minute revisions. Commissioner McKee said that his biggest problem with this is getting over his prejudices of using paper versus a computer. He asked if staff could help him set up over the next few meetings for him to practice using a computer. Todd Jones said that this could be put in place. Clerk to the Board Donna Baker said that the IT representatives usually come to every meeting. Commissioner Jacobs said that he hoped the ability to annotate the agenda would not be a limiting factor if they go paperless. He would like to see how an iPad works in the near future for this purpose. Commissioner Jacobs said that one of the reasons he uses his own computer is because he uses it all the time, but the County Commissioners have never discussed as a Board as to why they have a County computer. He said that it seems that if the County is making an investment in providing an expensive piece of equipment, then there are some obligations for how it is used. Frank Clifton said that there is an Information Technology training room and a demo could be set up there. Commissioner Gordon asked how the public was going to be served here in terms of access to the meeting agenda and meeting discussion and what were the rules for the Commissioners for communicating electronically. Todd Jones said that the public has the availability of electronic agendas now. Regarding the data exchange, he could work with the Attorney's Office on this. John Roberts said that you could either take the honor system or just block all of the data exchange. Commissioner Gordon said that she would like to see the cost savings. Commissioner McKee said that if using a computer will interfere with his ability to listen and engage in the meeting, then he does not want to use one. Deputy Clerk David Hunt said that in the past they have used `paperless' and `automated' verbiage synonymously, but they are not synonymous. An automated agenda system is what happens prior to the meeting with getting items approved, edited, updated, and ready for the meeting. Paperless is what the County Commissioners actually work with at the meeting. He does not think that the public would see a significant change in what is made available to them. He said that most places have a permanent meeting location, unlike Orange County. This makes implementation easier. 5. Adjournment A motion was made by Commissioner Hemminger, seconded by Commissioner Gordon to adjourn the meeting at 10:16 PM. VOTE: UNANIMOUS Bernadette Pelissier, Chair Donna S. Baker, CMC Clerk to the Board