Montgomery County Taxpayers League

The Voice of Taxpayers of Montgomery County, Maryland

MoCo Public Health Service – Efficiency and Effectiveness Review

Montgomery County Public Health Service

Efficiency and Effectiveness Review

By Montgomery County Taxpayers League

February 13, 2012

Montgomery xxxCounty Public Health Service Efficiency and Effectiveness Review

The Taxpayers League is grateful for the cooperation of senior management of the Department of Health and Human Services and of Council staff in the development of this report.

The Montgomery County Taxpayers League is a non-profit, non-partisan organization that advocates for taxpayers. It does so by (1) serving on County-sponsored commissions and committees that examine spending and revenues, and (2) meeting with County policy makers to understand and press for cost-effective government performance.

Recent efforts by the Taxpayers League and the County to deal with projected budget deficits have focused on the structural deficit, on imbalances caused by steadily rising employee health and pension benefits, on debt service and on reserve costs. Last year, the Taxpayers League was represented on the Organizational Reform Commission. Because fewer than half of the 2010 Organization Reform Commission’s recommendations were adopted, the League believes better program efficiency and effectiveness and new revenue sources can bridge the gap between revenue projections and the cost of needed services – without needlessly raising taxes.

Thus exercising control over costs is critical. The Office of Legislative Oversight projects that resolving structural deficits alone will not eliminate the gap between revenues and spending over the next five years. Its December 2010 report, Achieving a Structurally Balanced Budget in Montgomery County: Options for Long-Term Fiscal Balance, looked at employee salary and benefits only. It did not addressproductivity (“bang for the buck”), an important consideration for the County – and for the taxpayer.

The options to balance the budget include: an increase in taxes, establishing new user fees, reducing inefficient spending and eliminating effective programs. The Taxpayers League believes that policy makers should pursue all alternatives before embarking on tax increases.

We hope this report provides a framework for policy makers to make strategic decisions in this and other program areas from the perspective of the taxpayers of the County.

NOTE:  Footnotes are explained at the end of this document.

Executive Summary

This is our first report to help frame policy questions addressing such alternatives. Our focus is on the Public Health Service (PHS) which accounts for about one third the spending within the Health and Human Services Department (HHS), the third largest Department in Montgomery County. The PHS provides essential health services to our poorest residents and is central to how the new Health Care Reform Act will be implemented. We believe the slow growth economy and health care reform provide unique opportunities to look at innovative ways to reinvent which services are offered and how they are delivered:

  • Montgomery County taxpayers have been very generous

  • Residents up to 250% of the Federal Poverty Level with no health insurancereceive free health care (except for certain programs that require a co-pay)

  • Per capita spending on County health care is double the national and state averages

  • Salaries paid to County HHS employees are over 20% higher than Howard and Fairfax Counties

  • Local funding of HHS (70%) is the highest among nearby counties in Maryland and Virginia, and PHS relies on an even higher 80% of local funding

  • Health of our residents is above average but below that of Howard and Fairfax Counties

  • Our citizens live slightly longer but don’t do as well on selected health indicators (low birth weights, premature births, high blood pressure). These differences are not explained by demographic differences, higher rates of insurance, lower poverty and average age are better predictors of health outcomes than County program spending Services to higher income residents (those at 250% of the Federal Poverty Level) may be crowding out health care for our poorest residents (those at 100% of the Federal Poverty Level). Thus only an estimated 33% of our poorest residents at 100% of the Federal Poverty Level are served by PHS, which may account in part for lower levels of health performance.

  • Management challenges include better services integration and higher productivity

  • Services integration within HHS has been on-going since 1997, but must be completed to implement health reforms that include preventive care. This would likely stimulate higher performance than would additional employees or increased salaries in traditional programs.

County Stat performance measures are process oriented and ignore outcomes. Key outcomes that would demonstrate the effect of preventive care, such as teenage pregnancy, are not included

Productivity increases could yield significant savings. If Howard County’s hybrid salary structure for core services were implemented, Montgomery County would save $7 million annually. Building on Montgomery County’s Uninsured Health program, an undetermined amount could be saved annually through outsourcing. Furthermore, outsourcing could serve as a springboard for accelerating implementation of the integrated services model.

Background

Montgomery County’s Department of Health and Human Services provides vital health, welfare and housing services to our residents. It is the third largest County agency after the Public School system and the public safety agencies, with an annual operating budget of $250 Million, excluding benefits and other centralized costs. Local governments implement Federal and State programs, and our county is no exception, delivering services through over 60 programs.

The Public Health Service (PHS) is the largest health care delivery agency within the Department, accounting for about a third of all spending. Medical treatment for the uninsured and school health servicesare the largest program areas, followed by communicable disease control, health licensing and inspection of facilities, community health services, women’s health services, dental services and health preparedness and response.

The State regulates local Health Departments in core service areas. These include communicable disease, environmental health, family planning, maternal and child health, wellness promotion, and adult health and geriatric health. In 1996 Montgomery County worked with the State to gain exemptions from Public Health program controls that were thought to limit the scope and flexibility of services provided to residents. Included in this rationale was the belief that lower salary scales hampered productivity. These exemptions were triggered by reductions in funding by the State of core services for those counties with a higher ability to locally finance their programs1. As a result Montgomery County has a measure of autonomy from the state that allows it to independently expand services and innovate delivery methods to meet the unique needs of our residents.

Scope, Objectives and Limitations

This is the first in what the League hopes will be a series of reviews done in cooperation with the Council and agency staff. Our objective is to better understand how program efficiency, effectiveness, and revenues can be improved to meet strategic objectives for services, and sustainable revenues. We have released this report in time to provide recommendations for the FY 2013 budget.

PHS was selected for this review because it is central to implementation of the new Health Care Reform Act, and there are publicly available performance data on health outcomes, including benchmark data for surrounding jurisdictions. The fact that this program area provides vital services to our poorest residents during a period of slow economic growth was a significant factor as well. Lastly, the unique management autonomy this program area has from the State creates opportunities for evaluating improvements that can be implemented as initiatives at the local level.

These are the Inspector General’s definitions of efficiency and effectiveness from a reporting perspective:

  • Efficiency: Are actual and projected costs reasonable and accurately reported?

  • Effectiveness: Is the activity accomplishing its stated goals/objectives, and are the performance measures accurate and reliable?

The League has broadened these criteria for its review by asking some basic questions: first, is the program doing the right things; and second, is the program doing these things efficiently? Given that our review was limited to publicly available information, and information shared in meetings with senior management representatives, we could not get into too much detail. This is probably a good thing since we had to take a higher level, strategic perspective, one the average taxpayer who is not privy to inside information must also take. We leave to management, budget and Council staff more detailed analyses, and would appreciate feedback on how helpful this review has been for those follow-on efforts.

In order to weigh the information we obtained against our analysis and insight, we relied on management comments to help us provide a balance. Thus we have included those comments in our report. All who participated in this review are very busy this time of year and generously shared their time and ideas. We are grateful for the time that the HHS Director, Chief Operating Officer, Public Health Officer, and a Council staff member spent working with us.

Our methodology was based on the Federal OMB’s Program Assessment Rating Tool (PART), which is used to identify ways to improve performance with new strategies, and to link performance to budgets. A key feature of our approach was to benchmark county performance against peer counties. Our primary source of data was the published FY 2012 budget requests for Montgomery and neighboring counties as well as a Federal HHS data base of health indicators. We also met with the Director of the HHS Department, the Chief Operating Officer and the Public Health Officer to better understand the programs and issues.

Due to time and coordination constraints, we were not able to obtain the following information and have limited the scope of our findings, conclusions and recommendations accordingly:

  • Program Performance Data – To make comparisons with neighboring counties, the Director cited 20 selected indicators which are not currently in County Stat and which do not overlap with Federal Health indicators. However, these indicators were not made available to us. Thus we placed limited reliance on them. We understand that 14 of these measures are reported to the state as part of state-wide oversight, and 6 supplemental measures have been added by the County. Further, we relied on estimates for poor people served, since the program data does include household size, to differentiate truly poor (those at the Federal poverty limit of $23,050for a family of 4) from other uninsured.

  • Strategic Plan – The last plan for HHS was established 5 years ago and is currently being updated. While this presents an opportunity for this review to help shape the new plan, there was limited documentation of current strategies that could be used in our evaluation of program effectiveness.

  • State Health Program Costs – Salary costs for neighboring Howard County were not available to Council staff. Thus we had to rely on an estimate to analyze likely cost savings if Montgomery County were to implement outsourcing with Howard County’s labor costs that are a hybrid of state and local pay scales.

  • School Health Services – We were unable to find benchmarking data to compare to the limited performance measures the county publishes for this program. Consequently this program was only reviewed for outsourcing opportunities.

  • Outsourcing Benchmark – HHS management indicated that no formal studies had been done for the Community Health or School Health programs and no data was provided. Thus the scope of our review was limited to evaluating major change levers that would yield savings.

  • Overhead – Publicly available cost schedules do not show how many employees are directly involved in service delivery thus limiting our analysis of overhead.

Findings, Conclusions and Recommendations

  1. PHS PERFORMANCE

Community Health Status Indicators (CHSI-Attachment) show the county had health outcomes inferior to CHSI-designated peer Fairfax County, but better than Prince Georges and Baltimore counties, (both of which have higher poverty, lower rates of insurance and older residents, respectively). Fairfax County has a comparable insurance rate, but lower poverty and age rates, which may account for its better health outcomes. These higher outcomes combined with much lower salaries result in significant productivity advantages for Fairfax County. Outcomes for Montgomery County were also inferior to those of Howard County which the League used as a control for benchmarking. Howard has better poverty, insurance and age rates and employees are paid at a hybrid rate between county and state salaries which, combined with better health outcomes, results in higher productivity. Montgomery’s higher HHS salary costs contribute to higher per capita spending that is double the state average and the national median. If PHS were to adopt Howard County’s hybrid salary structure for core services, $7 million could be saved – without any change in performance levels. If the integrated service model were fully implemented with best practices for evidence based disease prevention, likely savings would be even greater. Estimating these savings was beyond the scope of this review.

Findings –

    1. State core service areas (based on our interpretation of the MACHO report2) would exclude the uninsured health program as a local initiative, as well as 3 other PHS programs that go beyond state minimums: STD/HIV, Dental, andEmergency Preparedness. This would leave 427.9 work years in core services out of a total of 509.3 work years.

    2. Maryland’s per capita state spending on public health (2007-8) averaged $38.13. In FY 2012 Montgomery’s per capita health spending is projected to be $68, or nearly double the state average and the national median of $33.71 (MACHO report, pg. 8). These differences are in part explained by high average Montgomery HHS salaries, $71,000, compared to just an estimated $55,000 in Howard county for hybrid state/county compensation rates, and $58,000 in Fairfax.Savings using Howard County average salaries are estimated to be $7M.3

According to a 2009 publication by the Robert Wood Johnson Foundation cited in the MACHO report (pg. 7) “evidence based disease prevention programs can result in improved physical activity, and preventing tobacco use. Such improvements are associated with reduced rates of heart disease, kidney disease, high blood pressure, stroke and type 2 diabetes.” Montgomery health indicators do not show improvements over other local jurisdictions despite higher per capita spending. Montgomery CHSI indicators should be favorably influenced by other preventive programs in the Department, but comparisons with Howard and Fairfax show that poverty and age factors may be more important in determining health outcomes. By enabling preventive health care, integrated services would likely provide more improvements than would higher spending on additional employees or salaries.

Management Response Sub-populations (e.g. blacks from Africa) need to be better understood to evaluate Montgomery health indicators. The HHS Director cited a recent study performed by PHS that shows how Montgomery compares to Fairfax and Howard Counties on 20 indicators (none of which are included in the CHSI data set, and many of which are process not outcome indicators). This study showed that Fairfax and Howard were about even with Montgomery in half the indicators, with the rest slightly above or below Montgomery. CHSI health indicators may demonstrate that HHS is still in the early implementation of its integrated model for service delivery, and this new structure may take a few more years to show a payoff in better health. Also, the Director and Council analyst believe the CHSI indicators do not reflect the direct influence of HHS programs, since there are many other factors that influence the health of Montgomery residents.

At a Taxpayer League meeting (December 16,2011) the Director stated that the 1996 reorganization required an exemption under state law for Montgomery to merge four previously separate Departments. This resulted in lower combined overhead costs, but also increased salary costs since Montgomery believed state salaries were too low to achieve needed productivity. Specific productivity improvements were not provided, but the Director asserted that 30% of customers need multiple HHS services and would benefit from integrated services. The Director believes that streamlined and combined “screening” and intake will help integrate HHS services, but integration of service delivery around specific customer needs is still ongoing. Technology and other strategies will eventually yield higher performance that overcomes the organizational silos that are exacerbated by separate Federal and state funding sources for many programs.

Regarding core services such as emergency preparedness, the Director said that this was a State mandate for which the County received State and federal grants. For preventive health care, there is limited funding for heart disease, high blood pressure, stroke and Type 2 diabetes and the County leverages these resources in partnership with hospitals, safety net clinics and other partners.

Conclusions and Recommendations –

Howard and Fairfax have better health outcomes that may be more attributable to better insurance and poverty rates than the performance of their Health Departments, although they may also be doing a better job with evidence based disease prevention programs. Since Howard County also performed well against the Department’s 20 selected indicators, our autonomy from the state, and Howard County’s decision to pay employees at lower hybrid salary rates may not impact performance although this is a limited judgmental inference. Montgomery County may not be getting an adequate return for its very high per capita spending on health.

Recommendation – Review older strategies based on earlier county autonomy initiatives, and develop new strategies that key on emerging issues related to slow economic growth, health care reform, increased poverty, and areas where county government can make a difference in health outcomes. Prioritize resources for strategies that improve health outcomes the most.

Recommendation – Review and adopt best practices in Howard, Fairfax and other local governments for evidence based disease prevention, as outlined in Robert Woods Foundation report.

    1. The county has many different health initiatives, and not all of them require the same level of health professional skill or compensation.

Recommendation – Determine how many employees could be compensated at the Howard County hybrid salary scale and still achieve the same superior results as Howard county. Determine if savings could be as high as $7M per year.

    1. The HHS integrated service model is a work in progress, and delays may be a drag on PHS performance.

Recommendation – Include in the new strategic plan specific near-term steps to pilot test service integration in high payback areas.

  1. HHS SYNERGIES

PHS represents about 1/3 of HHS staffing and spending. It is assumed that integrating the state’s public health programs with county initiatives has improved the performance of other HHS programs. This should be demonstrated by comparisons to other Maryland counties showing superior performance in programs like Children, Youth and Family Services. No publicly available information could be found for these comparisons.

Finding – County Stat and other performance measures included in the budget request for HHS tend to be process oriented, and are not useful in evaluating outcomes. Measures showing the percent of eligible residents served and the percent with favorable outcomes would be most useful for analyzing strategies.

Management Response The HHS Director believes that the new integrated services model has and will continue to improve the performance of other programs, but other counties in the state do not have data with which to benchmark this. There does not appear to be a common set of performance measures that are reported by other counties for comparison purposes. The selection of performance measures for the Department and for County Stat is something that is handled by the Department and the Executive Branch. HHS, under County Stat, tracks performance measures related to integration and the clinic/patient experience from the standpoint of systems integration and service delivery. Healthy Montgomery (community health improvement process) is selecting priority health areas and benchmarking data through a Steering Committee of government and non-government representatives.

Conclusions and Recommendations –

    1. Available performance measures do not support the claim that there are synergies when compared to other counties.

Recommendation – Develop measures and strategies in new strategic plan to specifically address which high priority components of the integrated services model will result in improved health outcomes.

    1. County Stat should include all, but only, performance measures that are deemed vital to management oversight by Executive staff.

Recommendation – Update performance measures to key more on outcomes, reserving process oriented measures for internal Department use.

  1. TEENAGE PREGNANCY

A $5M Federal grant was just awarded to study teenage pregnancy, which at 40 per 1,000 girls aged 15-174 is twice the rate of nearby Howard and Fairfax counties.

Finding: However, County Stats does not include teenage pregnancy as a performance measure. Data shows this has been a problem in Montgomery for years and that demographic differences do not explain the performance shortfalls. Fairfax has about an equal percent of Hispanics, while Howard with fewer Hispanics has performance similar to Fairfax.

Management Response According to the Director, teenage pregnancy is a new priority and hence its exclusion in County Stat.

Conclusion – As noted above, performance measures are under review and may not reflect strategically vital areas of health that require Executive oversight.

Recommendation – Determine if teenage pregnancy is a strategic issue that warrants inclusion in County Stat.

  1. HEALTH SERVICES FOR THE POOR

According to the FY 12 budget request, 23,000 of our 139,000 uninsured residents are targeted for health services. According to US Census 2010, approximately half of the uninsured (65,000) live in poverty. This review estimated that PHS provides health care to at least 33.4% of those at 100% of the Federal Poverty Level (FPL). Furthermore, the current strategic plan provides no strategies for increasing care to those at 100% of the FPL although management has established eligibility at 250% of that standard.

Findings:

a.In a period of austerity, the county should focus on how services to those at 100% of the FPL can be improved. According to the Public Health Officer, management’s 250% of poverty standard for eligibility is a negotiatedadministrative standard established to meet fiscal sustainability needs ofhealth service providers who prefer to includehigher income patients who can afford co-pays to offset overallservice delivery costs. These higher income patients crowd out those at 100% of the FPL. Also, co-pays improve the revenues of the contractors, but do not show up as revenues for the County (see Revenue discussion below). In the absence of a strategic plan or performance metrics for serving those at 100% of the Federal Poverty Level, management needs to determine how success should be measured for this population.

b. How many poor are served at 100% of the Federal Poverty Level is unknown and must be estimated. Based on a RAND study cited by management, a minimum of 33.4% are at this level. This is close to the Director’s estimate that 30% of PHS beneficiaries are eligible for Medicaid, generally a measure of how many are at the Federal Poverty Level.

c. Funding health care for those at 250% of poverty not only crowds out services to those at 100% of the Federal Poverty Level, but provides services to those who are better able to pay for health care some other way (e.g., through other family members). Leaving many at 100% of the FPL without care probably reduces the favorable impact of PHS programs on Montgomery’s health indicators, especially relative to other local jurisdictions

Management Response The Montgomery Cares Program for uninsured adults is a private-public partnership in which non-profit 501 -3c clinics work with Montgomery County HHS, the hospitals and Primary Care Coalition (PCC) to provide primary care health services. County dollars pay only a portion of the cost of care. These 501-3c organizations contract with PCC and not HHS.

In FY 2011, 26,500 residents at 250% of the Federal Poverty Levels or less5 were served by Montgomery Cares, and 28,500 will be served in FY 2012 based on reallocated resources. Current policy calls for moving those that are at or below 116% of the Federal Poverty Standard into Medicaid, if eligible, although many poor will remain in the Montgomery Cares program for the uninsured due to pending administrative actions. HHS does not track the number of residents served at 100% of FPL, nor does it track the number of illegal immigrants who are served. The new strategic plan, scheduled for July 1, 2012, may address this. According to Council staff, some data is available on the incomes of those served through Montgomery Cares, which show that at least 33.5% of those served are at or below the Federal poverty level.6 Management has asserted, without supporting data, that the Montgomery Cares Program for uninsured adults has more than 33% at or below 100% of the Federal Poverty Level, possibly closer to 55 -65%. Also, non-profits obtain revenue from private fund-raising supplemented by county funds and co-pays.

Conclusion– The current strategic plan and performance measures do not differentiate or focus on those at 100% of the Federal Poverty level. If only 33.5% of this population is being served, then more work needs to be done.

Recommendation – Develop better methods for measuring services provided to those at 100% of the Federal Poverty Level, and determine the feasibility of increasing their health coverage. Establish performance measures and new strategies in the new strategic plan.

  1. OUTSOURCING

Health care for the uninsured represents 19% of PHS spending, but only 3% of staffing, due to successful reliance on public-private partnerships. This $13M program is run with just 15 full time equivalents (FTE) and could serve as a model for reducing staffing in PHS’s two other large programs: Community Health Services and School Health Services.

Finding – Competitive responses by service providers would likely yield fully loaded labor costs lower even than Howard County’s hybrid labor costs, yielding significant savings. Performance standards could be used to incentivize providers to support integration of service delivery among PHS programs, using vendor case management systems to share patient information and lower costs. Lastly, incentives to deliver preventive health care with positive results could be incorporated into service provider contracts to lower program costs.

Management Response –Baltimore City contracts out school health room services, so this is not a legal or regulatory question. However, flexibility for how employees can be assigned to tasks is critical. For example, in the School Health program it is important to have consistent well-trained staff familiar with the children in the school because of the wide range of health care that must be provided on any given day. The County does contract out services for the school-based health centers but this does not include day-to-day management of the student population. The Baltimore City experience for privatizing school health was adifficult experience and one that the City is trying to undo. We do not recommend going down that path here in Montgomery County.

Conclusion Formal outsourcing studies would determine the feasibility and benefits of outsourcing Community Health and School Health programs, and are not restricted by state laws or regulations. Outsourcing savings could be significant because these services could be provided at far lower costs than county employees, and contracts could include performance incentives to reward integration among PHS programs and promotion of preventative health care. Savings could be used to accelerate implementation of the Department-wide integrated services model, and serve as a proof of concept model for outsourcing initiatives in the rest of the Department.

Recommendation – Conduct formal outsourcing studies, including best practices for successful outsourcing of these services. Incorporate the results into the new strategic plan for integrated services.

  1. REVENUE SOURCES

HHS as a whole is 70% funded by local revenues, the highest local funding rate compared with nearby Maryland and Virginia counties7. PHS relies on an even higher percentage of local funding, 80%. PHS, like HHS as a whole, has an over-reliance on local funding.

Finding – Increases in state and Federal grants and fees for service could be increased to reduce the burden on county taxpayers.

Management Response Data provided by the Chief Operating Officer showed local funding is 80% of the PHS FY 2012 approved budget. This is higher than local funding of HHS as a whole (70%) and reflects local funding of social services. The chart provided shows that just 20% of PHS funding comes from the state and Federal grants, and 7% comes from licenses and permits. Charges for services account for just 1%, half of county-wide average. In the past three years, State and federal funding via the State has been cut; in core funding alone, PHS lost $3 million from aid to local health jurisdictions. Health reform implementation will impact this funding picture.

Conclusion – Montgomery County places a heavy burden on local taxpayer funding for health services, and this is unsustainable given projected budget deficits. Charges for services to those above Federal poverty standard minimums would increase revenues and discourage demand for services by those above minimum poverty standards.

Recommendation – Review best practices of neighboring jurisdictions, and include new revenue sources in the new strategic plan.

  1. OVERHEAD

Overhead is composed of two components: direct and indirect. Our approach simplifies calculations by focusing on work years in each category, rather than actual costs. Council staff validated this approach with independent calculations for Department-wide indirect (administrative) overhead.

Finding – Our analysis of employees assigned to Service Area Administration Centers in the FY 2012 budget request, resulted in a calculated indirect overhead rate of 2% for PHS. However, this excludes employees who are not directly involved in service delivery but are assigned to program units. For example, community level maps of health data are compiled by PHS IT staff but these employees are not included in Service Area Administration. Experience shows that direct overhead costs can be many multiples of indirect overhead, depending on organization decisions. A 2007 OLO report8 recommended transferring certain HHS overhead functions to central county organizations, and the status of this and other plans to centralize PHS overhead activities needs to be determined for direct as well as indirect overhead employees.

Management Response Incomplete. Data needed to determine direct staff overhead for those who do not participate in service delivery was not readily available.Council staff analysis of administrative costs confirmed that this indirect overhead was 8% of the budget for HHS as a whole.A good overhead cost analysis will require more than an analysis of labor category data from the payroll system. For example, the county has many working supervisors who both supervise and provide direct service but would be included in direct overhead by just analyzing labor categories.

Conclusion – Available data is not sufficient to determine the number of employees not involved in service delivery. The direct and indirect overhead percentage may not be in line with other county Departments, other health organizations, or a generic world class overhead standard which is 10% in recent years. Without this data, management is unable to analyze and control staff assignments to direct overhead functions against such benchmarks.

 

Recommendation – Start with a simple but approximate study and develop a periodic management report and objectives. Use more extensive cost analysis, as warranted, for results that are superior or inferior to goals. Begin by obtaining a salary and headcount schedule from the payroll system, summarized by labor category. Determine which labor categories are most likely to be directly involved in service delivery and compute an overhead rate for the others. If the rate is greater than 10%, develop strategies to reduce these overhead activities to increase resources that can be directly assigned to customer service and improved outcomes.

8. CAPITAL IMPROVEMENT PROGRAMS

Unlikemany Montgomery County agencies there are few approved projects. However no data was provided that links capital spending to improved health outcomes.

Management Response There are just 3 approved projects pending: Dennis Avenue Wellness Center – $38M; High School Wellness Centers – $2.98M; and a school-based Health and Linkages to Learning Center – $2.09M. Some of this spending is needed to bring facilities up to minimum standards and this will improve capacity for providing services.

Conclusion – CIP spending is modest but not linked to specific improvements in health outcomes.

Recommendation – Continue to defer non-essential CIP spending that does not improve service delivery.

 

 

 

This Report was prepared by Gordie Brenne, Board Member, Montgomery County Taxpayers League

 

 

 

Attachments

 

MCTL- HHS/PHS Effectiveness Comparison

Selected Indicator

Montgomery County

Baltimore County

PG

County

Fairfax County

Howard County

Comment

Av Life Exp.

81

76.9

75

80.9

79.7

MC/How/FFx best

All Causes of Death

576.1

850.3

880

618.2

667.4

Per 100,000; MC best, no data expl.

Low Birth Weights

8.1%

9.4%

10.4%

6.7%

7.3%

 

Premature Births

12.2%

13.7%

14.3%

10.7%

11.5%

 

Adult Obesity

15.3%

20.8%

25.5%

15.1%

16.4%

MC 2nd best

High Blood Pressure

22.4%

26.2

26.2

19.4%

19.8%

 

No Exercise

18%

23.4%

24.6%

14.6%

15.5%

 

Uninsured

139K/15%

97K/12%

169K/21%

150K/15%

35K/13%

MC has good ins.

Medicaid Ben.

88K/9%

100K/13%

129K/16%

54K/5%

20K/7%

poverty proxy

Age 65 & Older

12.5%

14.5%

9.4%

9.8%

9.6%

MC is aging

Source: Community Health Status Indicators, Federal HHS.Gov, 2009; stop light rating based on study peer comparison and national medians where available

Findings

  1. Montgomery County– life expectancy and death rate are among the best in the country, but analysis of deaths (attached) does not explain this. Montgomery is in the middle of the pack on most measures, which correlates with moderate rates of uninsured and poverty. Older residents probably contribute to lower measures in obesity, blood pressure and exercise. Lower indicators for births has been attributed to the large Hispanic population which has a high rate of teenage pregnancies (39.7 per 1,000 females ages 15-17), but Fairfax County has a large Hispanic population with a teenage pregnancy rate that is half of Montgomery’s.

PG County– has significantly worse health indicators, which correlates with having a high rate of poverty and low rate of insurance.

Baltimore County– has the next lowest health indicators, which correlates with having a high rate of poverty and the oldest population.

Fairfax County– is a peer of Montgomery according to CHSI. It has better health indicators than MC in most areas, which correlates with its lower rate of poverty and younger population. Also, its HHS FY ’11 budget is the largest of the group, averaging $4,667 per person in poverty, compared to $3,844 in Montgomery, and $3,270 in PG, according to study this year by MD Budget & Tax Policy Inst.

  1. Howard County– has the best health indicators, which correlates with its higher rate of insurance, low rate of poverty, and younger population. The Taxpayers League uses Howard County for benchmark comparisons because it neighbors Montgomery, has higher median household incomes, and provides useful insights about the role of income and economic development policies for performance in Maryland.

Death Measures

 

Causes

Montgomery County

Baltimore County

Prince Georges

Fairfax County

Howard County

US Rate 2005

Comment

Heart/Stroke

145.3

224.6

246.2

125.2

191.9

201

Per 10,000

Cancer-Breast, Colon, Lung (add)

66.8

105.4

100.7

75.1

72.1

94.2

Per 10,000

Accidents

9.6

12.9

16.4

15.6

7.7

39.1

Per 10,000

Motor Vehicle

6.6

10.0

15.1

6.1

7.3

14.6

Per 10,000

Suicide

5.6

8.9

7.1

7.8

7.7

10.9

Per 10,000

Homicide

3.8

7.6

18.8

2.3

2.3

6.1

Per 10,000

Infant Deaths

6.1

8.2

10.9

4.5

6.8

6.9

Per 1,000 live births

Source: Community Health Status Indicators, Federal HHS.Gov, 2009; stop light rating based on study peer comparison and national medians where available

 

 

 

Demographics

 

Indicator

Montgomery County

Baltimore County

Prince Georges

Fairfax County

Howard County

White

70

69

28

72

68

Black

17

25

66

10

17

Asian

14

4

4

16

12

Hispanic (non add)

15

3

13

14

5

Population

971K

805K

835K

1081K

289K

Med Hshld Income

$89K

$77K

$70K

$101K

$103K

Jobs in County

654K

375K

302K

856K

147K

 

1 Core Funding for Local Health Departments, Maryland Association of County Health Officers (MACHO), 5/5/2010. Management has responded by saying that the exemptions were in response to drastic cuts in funding for local health that began in 1992 and again in 1993. Secretary of Health, Marty Wasserman, lay the foundation in 1994 to codify the Case Formula and Core Funding. Local matches to the State base funding were established in 1996 as well as the array of allowable core or essential services for which the funds could be used. Montgomery County, other than being a home rule county, was treated no differently than other local jurisdictions in what core services were permitted.

2 ibid

3 $7M=427.9 core service FTEs times salary difference (71,000-55,000).

4 According to Community Health Status Indicators, Federal HHS, 2009 (CHSI), and as updated by Gazette article September 28, 2011), “Study Access to Reduce Hispanic Teen Pregnancy”

5 2.5* $23,050=$57,625 annual income for family of 4

6 Data included in the 2009 evaluation of Montgomery Cares completed by RAND Health. Family Income from Work for Montgomery Cares Patients in 2008: Less than $10,000= 33.4%; $10,000 to $25,000= 48.3%; $25,000 to $35,000= 12.3%; More than $35,000= 6.0%. This data is not is not provided by family size so it cannot be broken down by percentage of FPL. However, FPL for a family of 1 in 2011 is about $10,900 and for 2 is $14,700 so it is likely that most are well below the 250% of FPL.

7 Maryland Budget and Tax Policy Institute, “Funding Health and Human Services: Comparative Budget Analysis for Prince Georges County”, May 2011

8 Office of Legislative Oversight, Kristin Latham, “Inventory of Internal Service Functions Performed by Five Montgomery County Departments”, July 31, 2007