MINUTES OF THE INFORMAL MEETING OF THE JOHNSON COUNTY BOARD OF SUPERVISORS:
JANUARY 5, 2009
TABLE OF CONTENTS
Page
Departmental Budgets........................................................................................................... 1
FY2010 County Budget............................................................................................ 1
Mental Health/Disability Services (46)...................................................................... 2
Chairperson Neuzil called the Johnson County Board of Supervisors to order in the Johnson County Administration Building at 9:01 a.m. Members present were: Pat Harney, Larry Meyers, Terrence Neuzil, Sally Stutsman, and Rod Sullivan.
Neuzil asked Budget Coordinator Rich Claiborne how the official numbers from the County Auditor, County Assessor, and County Treasurer were coming along. Claiborne said they were slightly higher than a couple of weeks ago. Neuzil asked when they will follow up on the Board's questions. Claiborne said those questions will be answered in future meetings. He said things become clearer as Claiborne moves through the budget process. He said he has all of the departments input in GEMS except for Mental Health/Disability Services (MH/DS) because they didn’t have their budget ready yet and the Board will be receiving it today. Claiborne said he is working on the spreadsheets to see where the levy is. Neuzil said the next scheduled meeting is January 7, 2009 at 1:00 p.m. for Block Grants and there is a meeting scheduled on January 12, 2009. He asked Claiborne if that would give him enough time to address the Board's questions. Claiborne said he would let the Board know when meetings are needed. He said right now it is premature to schedule a meeting. Neuzil said there is a meeting scheduled for the week of January 12, 2009 at 9:00 a.m. and another one on January 21, 2009 at 1:00 p.m.
R. Sullivan said he would like to go over the Board's questions again to clarify many things. Harney said he knows that Claiborne is busy, but the tally sheet isn't up to date either. Neuzil said on January 7, 2009 the Board will go through Block Grants, the tally sheet, additional questions, and then get some answers the following week. Claiborne said sure. Neuzil said it is hard to budget when the Board doesn’t know how much money the County has. Claiborne said right, it is all a process. He said every year when this process begins, the department meetings are held prematurely of having answers. The serious planning meetings will be held the week of January 12, 2009.
R. Sullivan asked Claiborne to clarify the data input into GEMS and if when the Board requests something taken out how that is done. R. Sullivan asked if Claiborne enters the full request and then removes it if the Board says to take it out. Claiborne said he does not enter all the data into GEMS. He said that is on the user spreadsheet which includes the requested and tentative budget and the requested budget includes decision packages and the tentative budget is the bare budget. Executive Assistant Mike Sullivan said things are not put into GEMS without the Board's authorization. Neuzil asked Board members to review their notes from the budget meetings and be prepared with follow up questions on January 7, 2009.
Mental Health/Disability Services (MH/DS) Director Kris Artley said the budget is not finished. She said she is presenting a draft version and some crucial decisions must still be made. She said the growth in the program has been off the charts. This makes budgeting very challenging. Neuzil said it seems like they are in the situation the legislature wanted, to provide less money. Artley agreed and added that this is an inopportune time.
Artley said the State used to be very good about sending quarterly payments, especially for local purchase dollars. Now the State sits on all the money to draw as much interest as possible for as long as possible. Approximately one third of the MH/DS budget comes from the State. She said cash flow is a real problem when the State doesn’t pay until January. Artley said MH/DS will get property tax relief dollars in July and January, but the money from the State for allowed growth, community services, and local purchase dollars comes in one lump sum in January, 2009. R. Sullivan asked if that is $7 million dollars. Artley said yes. R. Sullivan asked if that is half of the MH/DS budget. Artley said it is approximately one third of the budget, but if property tax relief dollars are included, then yes it's about half the budget. She said the State used to spread those payments out but now they do not and this causes the cash flow problems.
Artley said she has told staff not to pay anymore State bills right now. She said there is not enough money to pay the bills. She said MH/DS will keep the lights on and pay salaries but that is it. Artley said the timing of the States allocation of money is a big issue. She said there is nothing that can be done except complain like last year. She said MH/DS received a check from the State within 24 hours after they complained. Stutsman said the State was procrastinating then. Artley said five years ago while she was working for Franklin County she had to call to get money owed them and the State cut their checks one week after her phone call. She said the right and left hands in Des Moines do not always coordinate well.
Artley asked for clarification on the current utility property tax line item. She said MH/DS has budgeted for that every year but never gets anything. She was inclined to make that zero. Stutsman asked if that is what they are paying for rent at 911 North Governor Street. Harney said the County pays taxes on that. R. Sullivan said he thinks this is the revenue from MidAmerican. Artley asked if they ever get any money. Claiborne said a lot of the tax things come from Deputy Auditor Mark Kistler and these are the final steps when the entire budget is done. He said he does not do anything with many of the departmental budgets until the end. R. Sullivan said this is taxes paid on things like pipelines and high lines that are real property but go across someone else's property with easements. He said those companies still pay a little tax. Artley said they got nothing in 2006, 2007, or 2008. She asked if she should be budgeting anything for that line. R. Sullivan said he doesn’t know why that is zero he just knows that is what it is. Neuzil said that is a question to ask Kistler. Stutsman asked if MH/DS gets the revenues from those taxes. Harney asked why it would go into the MH/DS budget. Stutsman said she thought it was clear in the legislation that there would be only certain revenue streams in the budgets and she didn’t know that was one of them. R. Sullivan said maybe that is why it is zero. Neuzil said Artley is right, there is no need to budget for revenues if they will never be received.
Artley said in 2006 it was budgeted for $71,000. She asked the Board if they were possibly thinking that it is not available to MH/DS. Stutsman said correct. Artley said okay she didn’t know that. Stutsman said that needs to be confirmed. R. Sullivan said it also could be an Auditors Office issue where they only have so many lines available and they merge line items together. Artley said nothing has been received for the past three years and she is reluctant to put almost $45,000 there. She tends to want to zero that out unless the Board can convince her otherwise. Neuzil said as R. Sullivan pointed out it could be part of the revenues. Artley said for her the revenues are her monies to expend and that is why she really does not want to count it if it won't be available. She said she knows Financial and Statistical Supervisor Deb Guard sent over a question about why MH/DS carries a minus $1,902. She said she is not sure she understands that either. She asked the Board if that should stay there.
Artley said she wanted to remind the Board that their directive was to use the same numbers as previous years. She said mostly that is what was done and things are really skewed. Harney said that looks like a safe guard. Artley asked if that should impact the mental health budget since that is a fund. Neuzil said the Board will definitely need to follow up on that also. Artley said she got a kick out of the delinquency real estate taxes in FY08 because they got a minus $83.00.
Artley said she is seeing a steady decline in the utility tax replacement excised taxes. She said that is why she brought that down to $56,500. She said she does not know what the methodology is as far as how that money gets there. Neuzil said obviously it looks like a phase out of that tax from the State. Those numbers keep dipping down. Artley said she lowered that because of what was happening historically. Artley said based on what MH/DS was submitting for billings and receiving for revenues, she could not understand why $2 million was ever put in as an amount for revenues. She said she found a little note stuck in the files and she thinks at one time the intent must have been that Johnson County was going to find a way to bill for County social work services. She said in other words the County would bill itself, pay itself and then bill the State. She said maybe that accounts for how high it was. As of the first five months MH/DS was averaging $112,000 per month. She said last month it dipped down a little bit. She said she dropped that down to $1,400,000.
Artley asked the Board when they became aware of the huge population growth. Stutsman said it seems like Artley has become aware of it overnight. Artley said it just mushroomed. Stutsman said she doesn’t understand the growth either. Artley said she determined there was a 21% growth for case management in FY08 and during the first quarter they have already seen about a 4% growth. She said the County has reached a saturation point. Right now it is the fact that there is not enough space for the people until MH/DS gets moved. Stutsman said she doesn’t see where a growth in the general population produces a growth in the department like this. She said she is wondering if other counties are sending people here because of their fund balances. Artley said Johnson County is not responsible for individuals until they establish legal settlement in the County. She said she does think MH/DS was hit hard with the State cases. She said another problem is the folks that get into trouble in Linn County because those people are shipped to the Abby Center which is a very expensive rent. She said they have seen over a 50% growth in expenditures at that level of care. She said everyone is going through the court system.
Artley said the Interim Assistance Reimbursement Program was just started. She said she is only putting $1,500 and she hopes there will be a lot more. She said those are reimbursements from other governments that come directly from social security. She said at this juncture it is unclear what will be received. She asked if anyone from the Board could explain what the "refund of prior year expense" means because they received some money last year. She said she plugged in another $22,000. Stutsman said the only thing she can think of is if the previous MH/DS Director Elaine Sweet paid out money and agencies had to pay it back but she thought the Board zeroed that out. Harney said he thinks that is right. R. Sullivan said yes, that was a one time revenue. Artley said they received revenues in FY08. R. Sullivan said Deputy Auditor Dana Aschenbrenner should be consulted about this. Meyers said yes because FY07 is way off as far as those numbers go. Artley said in 2006 there was a tremendous amount.
Claiborne said he wondered if that was an accrual thing actually. He said the County runs on a cash basis but the financials have to be run on an accrual basis. He said he knows there are cut offs for vouchers, he said he wonders if they put a voucher in for FY09 when it should have gone to FY08. M. Sullivan said he thinks that is what it is because there are other department budgets that have a "refund of prior year expense" revenue lines in them. Claiborne said almost all of them do. R. Sullivan said they will have a 60 day cut off and these are revenues that came in after the 60 days. M. Sullivan said right. He said when claims come in they are supposed to be marked a special way with a red A on the claim form so the Auditor's Office knows its an expense that occurred in 2008 but was actually paid in 2009. Artley said right, for expenditures, but this is revenue. M. Sullivan said yes but it will come in as revenue. He said it will be an expenditure that went out but it wasn’t reflected and since the County is on a cash basis and the auditing is done on an accrual basis it wasn’t reflected in the 2008 budget. He said what the Auditor has to do is refund it back in to 2008 revenue line, same thing with 2009. He said this is one where there is no real way of knowing how much revenue to budget for. He said that is why there is the difference between $27,700 in 2006 and it drops down to $130 in 2007 but the actual is $1,400. He said this is a tough one.
Claiborne said governmental accounting is a lot different than private industries. Artley said all she could do was look at history. Artley said she knows that one year when they were still having the quarterly payments of local purchase the State did not have enough monies and so they only gave a certain percentage for the fourth quarter. She said the state gave the County a balance in July at the beginning of the next fiscal year, but that would have gone back into the local purchase dollars. M. Sullivan said yes. Artley said this is just a big question mark.
Artley said the allowable growth for the current year is around $3 million. She said a check has not yet been received. MH/DS has budgeted $2,882,000 and that was bumped up slightly for the next year. Local purchase is one of the things that continually tends to slightly decrease. She said the annual revenue from 2006 was $711,000 and in 2007 it dropped to $634,000, then it bumped back up to $708,000. She said just to be safe they brought that back down a little bit. She said Community Services indicated they would be right at $1 million. In the last report in June, the Auditor's Office switched the dollars for Community Services and Allowable Growth because they were backwards. Artley said she put it where it needs to be on the Auditor's report. She said MH/DS is no longer collecting client participation fees; it was not worth the internal effort. She said they were only generating $6,000 to $8,000 and spending a lot of time and getting bad checks from people that MH/DS had to pay for.
Artley said County case management is when the County has been asked by other counties if MH/DS will serve their person and those counties pay the department directly the case management rate. She said there has been a steady increase and she left that item at $10,500. R. Sullivan asked if those were people who are not Medicaid eligible. Artley said yes. Counties request MH/DS to serve those people because they live in Johnson County. She said so far they have said yes but they must continue to evaluate if it is cost effective to continue.
Targeted case management is a real bearcat right now because Artley and Guard will not find out until the end of the month how IME will dictate how MH/DS converts from a monthly billing to an hourly unit rate. Artley said based on all the information they have been tracking, she has a lot of apprehension as to if all of the administrative costs are going to be covered. The targeted case management budget could probably be bumped up a little bit. She said she and Guard had settled that they would take about 80% of what they guesstimated for the return. If current growth continues that amount of revenue could be substantially higher.
Artley asked the Board what was sold from the CPC as a capital asset. Stutsman asked if that was the Quilogy program with Polk County. She said if other counties bought it. Artley said that would explain why it bumped up in 2007 but it earned only five dollars in 2008. She said that is why it does not make sense to her. She asked if the Board thought that was Quilogy. Stutsman said yes. Artley said she is zeroing that out and the best course of action is to go through ISAC's project which is connecting with the State. It will provide a systematic approach for every county so everyone is collecting the same data and entering it centrally. It will also allow the State to bill in through that system directly to MH/DS no matter what type of system the department is on, so there will be consistency. This allows the bills to be accessed electronically. She said except for the $44,943, she is inclined to take that out. Neuzil said the Auditor's Office should be consulted to bring clarity to some of the questions raised today. He asked Claiborne to help Artley with that so everyone is on the same page.
Artley asked if any of the Board has a sense of what will happen with the patient advocate position. She said that position is a State employee and for three years there has been a committee to review the status. That cost to Johnson County is approximately $66,731. Stutsman said she thinks they bring it up every year but she would be surprised if the State takes over anything new. She asked if it was paid out of the Courts budget. Artley said MH/DS pays it. Stutsman said if it were taken over by the State it would have to be out of the Court system. Artley said she knows 6th Judicial District Court Administrator Carroll Edmundson was on the committee to draft a job description so there would be some uniformity because there is no continuity across the State of Iowa for this position. She said the Board is very fortunate to have the women who is very dedicated but that would be a cost savings if the State would step up to the plate in that venue. Stutsman said when they have been asked to cut so many budgets she would be stunned if they took over that position. Neuzil said yes there will be no new programs. R. Sullivan agreed.
Artley said she has not finalized the section for Jail Alternatives and Mobile Crisis. She said they are in the process right now. Today is the day Community Mental Health Center Director Steve Trefz is supposed to have his grant application into the State for the Mobile Crisis Emergency Fund working between the MH/DS and the Abby Center in Linn County. The intent is that Trefz will have staff who will respond to anyone in crisis. She said his direct question to MH/DS is whether the Jail Alternative staff can go and work with those people who received crisis center intervention and help connect them back into Community Services or whatever they need. She said she thinks that is a very appropriate request based on the circumstances. Artley said they are trying to avoid hiring any new people in the County because the money only runs from when they finally award it until June 30, 2009. She said she knows State Senator Joel Bolkcom offered seed money. She does not know if that money will grow or evaporate after this year. She said she is totally in agreement with Trefz that no new people should be hired for this short term operation and she is more than willing to support him in this effort for the emergency crisis.
Artley said there are several other issues. The coordinator position which was a $50,000 salary job is not needed at this juncture. MH/DS can no longer afford the coordinator position either. She said if the Sheriff's Office wants more than is budgeted, and/or the County Attorney's budget, the Sheriff will need to help out with this venture. She said MH/DS can not absorb all the cost anymore. Artley said she didn’t want to augment the Jail Alternatives/Mobile Crisis budget at all. She said she would prefer to take the money allocated for the coordinator benefits and wage salary and move it over into the service arena. Artley said she does not think they will be able to grow that program right now. She asked the Board if they approved of her moving those dollars.
Harney said when this coordinator position was originally put into place, it was required that applicants had to be qualified to diagnose and make referrals. He said it seems like the program is getting along without that but he knows Mindy Lamb, the previous Jail Alternatives/Mobile Crisis Coordinator, had that and it was the big issue at the time. Artley said Lamb had those qualifications and because of her experience with the first two young girls, staff was convinced they had to get their LISW, Licensed Independent Social Worker. Part of that licensure is the diagnosing component. She said the women keep pushing the need to be able to diagnose. She said the newest hire, Emily Herst, is an LISW and she came from the Mental Health Center. The other woman is a Master Social Worker and she has chosen to secure her LISW. Artley said her personal apprehension is that by the time Herst gets the licensing she will move on to bigger and better things. Artley said for MH/DS to execute diagnosis, a physician's signature is required. However for the purpose of working with the Court and Attorney's Office they can do in-depth assessments and make pretty good recommendations based on their qualifications. Artley said she is very reluctant to say they are diagnosing. She said she knows that was a big hot button.
Stutsman said she thinks what happened is some of those people were hired with the idea that they would eventually get their LISW. Stutsman said she would agree with Artley if the feeling is that LISW is not necessary now. She said the focus and the program have changed and it is just not fitting in with what the County needs or is able to afford. Artley said one staff member is a LISW and another is working on it. She said she keeps asking them where are the guidelines that make them feel they need to be able to diagnose. The women tell Artley that it is part of the criteria for the LISW and Artley said she wants to know where the State guidelines are that say they need to be certified.
R. Sullivan said he wants to make sure he understands this issue correctly. He gave a scenario where staff encounter somebody in jail that Johnson County has never had contact with. Before a person is going to have access to any County or Medicaid services, he/she is going to have to see a physician. R. Sullivan said whether the staff can diagnose that person or not doesn’t matter because they will have to make a doctor's appointment anyhow. Artley said exactly. Stutsman said it is a duplication of service and in tough government times the County can't afford this. Harney said he thought it had something to do with conducting an evaluation in the jail. Artley said they do an assessment, but she would not call that an evaluation because there is no physician's signature. She said they conduct assessments. If a patient qualifies for Medicaid they must have a physician's diagnosis.
Harney asked where Artley wanted the money moved to. Artley said that she wants to move it over to the service arena. She wants to zero out the Coordinator position. Harney said that is not saving the County any money. Artley said no. Stutsman said no but it will guard against cutting services or putting people on waiting lists. Artley said they definitely need it in the service arena and they are not able to hire for that position right now. Harney said he doesn’t have a problem with providing services but on the other hand that is going to be an increase in the budget for more services if the $50,000 is moved over. Artley said the $50,000 plus benefits is already in the budget. She said it is budgeted for an empty position. She is proposing to zero out the empty position line item and move that money to services to offset the increased cost there. Stutsman asked if the two individuals are able to handle the Jail Alternatives program. Artley said right now they are doing a beautiful job. She said they are not able to spend inordinate amounts of times tracking all of the finer points but she would rather see them with the people and getting them connected. Stutsman agreed.
R. Sullivan said he hopes the County never has to cut services or have a waiting list. He said if that point is reached, he wants to make sure the County is not administratively top heavy. He thinks that is the worst possible mistake to hire on more clerks when there are people who have to wait. R. Sullivan said it is important to be lean and mean if patients will be put on a waiting list. Artley asked if Stutsman shared with the Board information about the waiting list for waiver slots. Stutsman said she has not. Artley said going into January 1, 2009, there were seven people on the waiting list but fortunately it is now down to four because some of the people choose to go onto other things. She said the numbers were submitted in October 2008 and before January 2009, there was a waiting list. Stutsman clarified, these are the kids that are aging out and usually there is a pretty good indication that they are coming into the adult system. Artley said right, the kids that are aging out automatically get a waiver spot. She said they have to give them one, but there are also those who are for the home community based waiver for the MR population.
Artley said the Board could earn political favor if they would lower the poverty level slightly. She said they get lambasted every time someone establishes residency here and people say the poverty level is 250%. Anyone below that qualifies. Artley said MH/DS did an analysis and if the County were to go down to 200%, 34 funded cases would probably cease to be funded: nine chronically mentally ill, 22 mentally ill, and three developmentally disabled. There are three clients that have State case status and for those folks, MH/DS is paying out about $37,000 annually. This does come back in revenue for those folks, but the remainder of people have Johnson County legal settlement and it encumbers the services around $200,000 annually. Stutsman asked how many clients that would affect. Artley said 34 funded cases. Stutsman said decreasing the poverty level would mean that those 34 people would no longer be eligible for County assistance for services. Artley said if the County went down to 200% poverty. She said the lowest threshold is 150% and that is where most of the counties are.
Artley said Johnson County is very benevolent at 250%. Neuzil said this would take affect July 1, 2009. He said folks should be given time to look at services. Neuzil said there should be a Planning Council discussion. Stutsman asked if that would amount to $200,000. Artley said the guesstimate was based on the current service package and it would save an annual amount of $200,000. R. Sullivan asked if Artley knows what the poverty rate is right now. Artley said she does not have that memorized. Artley said they use the federal poverty guidelines. She said it is in the Strategic Plan. She said the federal poverty guidelines change between January and February but the County waits until the following July to change. Neuzil said it is all about funding of last resort. R. Sullivan said if the people who are eligible for this now are moved off the list, there would be money available for people who are in a lower income bracket. He said in a way the money is still being spent on the neediest people. Some of the people whose income then exceeds the poverty level are going to have existing relationships with psychiatrists and it is important to be mindful of possible disruptions because that could cause more costs down the road. Neuzil said there is at least interest in exploring it.
Artley said if the County truly gets to the point where residency is the guiding factor then there will be uniformity one way or another across the State and she can't believe that the State will pick up on the 250% poverty level. Stutsman asked how many counties are at 250%. Artley said not very many. Neuzil asked Artley to gather that information for the Board. Neuzil said it will help them justify their positions. Artley said there are some counties at the 185% poverty level. Neuzil said Artley may consider a phasing down process. Stutsman said if the Board decides to make this change, the sooner the better. She said it will be better to let people know what is coming.
Artley asked Neuzil why the County Rate Information System (CRIS) cost keeps going up. Neuzil said a few counties dropped out. He said he thinks there is just an adjustment. Stutsman asked what Artley meant by "they keep going up." Artley said participation costs. R. Sullivan said membership costs. Neuzil said the only real expense that organization has is the auditing firm that does it. Neuzil said a few that dropped out partly because one of the CPC's left and then their Boards of Supervisors didn't renew memberships. Neuzil said they just didn’t want to pay the thousand dollars. He said he thinks there are going to be some changes with CRIS and ISAC in the future.
Stutsman said the Federal poverty guideline for 250% is $53,000 for a family of four. Artley said that is a pretty good substantial income. R. Sullivan said that is Johnson County guidelines. R. Sullivan clarified, that’s 250% not 100%. Stutsman said yes, 225% would be $47,700, 150% is $31,800. Artley said if the poverty level was only dropped to 200% it is still reasonable for most people. She said the Board has been benevolent with services, the availability of monies, and exceptions to policies. She said policies are changing dramatically in one arena and that is what she wanted to reference in conjunction with a psychiatrist.
Artley said MH/DS is having a really hard time retraining psychiatrists thought processes, because they want to do business as usual. She said historically the Board has been flush with psychiatric hours which means everyone gets to go see the psychiatrist once a month forever. Stutsman asked if the County was paying for counseling through a psychiatrist or just for medication management. Artley said she thinks counseling too. She said they do not delineate well between counselors and psychiatrists. She said historically in the central part of the State, where there were no psychiatrists, she was lucky to get somebody in for the first two months under crisis mode and after that it was once a quarter for medication management. Anything else was strictly done with counseling, and that is why there are satellite services so counselors would come to the different locals. She said the people managed to get by, but here, there are lines of people waiting.
Artley said under pressure from the Management Plan Re-write Committee, the psychiatrist said there has to be something in there to cover emergencies. Artley said exceptions to policy will be based on the psychiatrist's professional expertise. She said when July 1, 2008 came there was a pile of exception to policy requests. The psychiatrist's and therapists had gone through their entire patient roster and asked for sessions all the way through the rest of the fiscal year for any patient that had a cut off point. Artley said no to that request saying it would be enabling. She said MH/DS will either take patients through their anniversary date, or at most six months out. She said patients do not have to stay under a psychiatrist care forever. R. Sullivan said they may have to stay under the psychiatrist care forever but maybe for bi-annual visits. Artley said this is for once a month visits. R. Sullivan said a person is under a psychiatrist's care if they have a prescription, but that doesn’t mean they have monthly appointments. Stutsman said it might not be the best use of the psychiatrist's time.
Neuzil asked what the cost of a psychiatrist was. Artley said a psychiatrist at the mental health center is over $300 an hour. Neuzil said that is why this needs to be addressed. Artley said she could send them to the University of Iowa much more inexpensively but then the Mental Health Center would go out of business. Neuzil said Artley has to continue to keep an eye on all of these expenses. Artley said everybody from the psychiatric business has been requesting exceptions to policy. She said one of the medications was taken off the formulary because the generic was more expensive due to the pills dissolvability. She said they went through MPS, the hired pharmaceutical representative, and notified the psychiatrists who expressed great dissatisfaction. Artley said she told them that they can prescribe this in the other format or in two other degradations of milligrams. R. Sullivan said the psychiatrist issue might be a good topic for the Planning Council because it doesn’t seem to make sense for just the Board and Artley to know about this.
Stutsman said she would agree but the chronically mentally ill have a very organized advocacy group and sometimes she is concerned how much of the budget goes to CMI versus the other disabilities. She is always concerned because the need is endless, but when managing a fixed budget, choices must be made. R. Sullivan said that is a good example of where a painful process for MH/DS worked out. Artley said they also had a phasing period which said one has to apply for the patient assistance program in order to get their pharmaceuticals for free. She said then the Mental Health Center became adamant saying they were not a pharmacy and couldn’t store all the medications. She said bottom line if the Mental Health Center does not want to accept this she can send the patients to the University of Iowa.
Artley said last year she got together with Edmundson, County Attorney Janet Lyness and Clerk of Court Lodema Berkley and negotiated a contract for the mental health referees. She said there are two referees in the County and she does not think they are billing according to the billing agreements which was based on supplying information on individual people. Artley said during the course of watching the bills come in it is apparent that the referees also do the court hearings for people with substance abuse. She said when she asked Edmundson about that, he told her the referees said they do that "pro bono." But Johnson County has a set fee and is paying them $15,000 per month. Artley asked if the Auditor's Office runs the substance abuse budget. R. Sullivan said yes. Artley asked if the Auditor's Office historically pays for referees or magistrates. R. Sullivan said yes. Artley said a few of the substance abusers are falling through the cracks and she is not sure they are getting the best return on their dollars. Stutsman asked what difference it makes since it is a fixed amount. Artley said right, and she is not convinced that is the best plan. She said they should be billed per case because in October 2008 they were swamped with cases, but then the caseload dropped significantly in December 2008.
Artley said there was a tremendous number of people referred to MHI's and significant growth in Woodward and Glenwood, the State resource centers. Because of that growth those are very high quarterly bills from the State. She said they were somewhat sadly fortunate that two of the people at the Clarinda Geriatric Unit passed away so they did not cost the County very much for very long. She said when the court orders services it is hard to deny them. Artley said they try to get to those people when they are still in the hospital state and work as hard as is possible to find community services. Stutsman asked if some of the substance abuse cases are being referred. Artley said some are being referred to Mount Pleasant for the dual diagnosis and they will not accept them until MH/DS and the Auditor's Office signs off. She said MH/DS pays one quarter, the Auditor's Office pays one quarter and the State picks up the other half for the substance abuse. She said the dual diagnosis at Mount Pleasant is not cheap and MH/DS is obligated to cover that.
Artley said there was tremendous increase in residential facility psychiatric mentally ill placement, a very high cost residential care. She said not all of the folks going in are based on the MHS protocol. Some of them are based on residency because of Linn County and the Abby Center. She said the courts are also referring people to that level of care. Artley said they did offer, with the new management plan, an opportunity for the case managers to work with their clients to balance either the vocational services or the Supported Community Living Services (SCL) as a combo not to exceed a maximum of $13,050 per month. She said initially they considered $12,050 a month. She said they tried to take a look at what people were receiving and decided to be a little bit more benevolent, but that could be lowered. Artley said she will discuss the vocational SCL combination rate with the Planning Council. It appears a lot of people are going for the maximum and that would save substantially. She said in October they had too many court commitments and more and more senior citizens going through the system. This is disturbing because they are entering the system with dementia and they are being court ordered into mental health services.
Artley said for the first six months of 2008, 210 adults and eight children went through the court committal process. Of those, only 69 had Johnson County legal settlement. She said 35 individuals were State cases, 100 were out of county, four were unknown, and ten were out of state. She said normally they would try to make State cases for the unknowns and out of state cases and those cases totaled 14. However Des Moines refuses to accept them because they have no intention of residing here and the State payment program is based on residency. Stutsman asked who pays for them. Artley said Johnson County absorbs the cost of attorney's fee, Sheriff's fees, and if there is not an open bed at the University of Iowa Hospitals and Clinics, the County also absorbs the cost of hospitalization elsewhere.
Stutsman asked why the court does not recognize dementia versus mental illness. Artley said she thinks that when a patient acts belligerent in nursing homes, panic sets in among the staff. All it takes to commit someone is for two people to file papers. The mental health referee only hears about that one belligerent incident and since they don't know what it is, they do a court committal. She said she is curious to know why they don't inquire if that person came in with a diagnosis and if so, what that diagnosis was. If it is any form of dementia, it should be treated differently. She said suddenly the hospitals are catching all these patients for evaluation and often times the nursing homes refuse to take the people back. Artley said these people are stuck in the hospital for four to six months, no exaggeration. That is when requests are made to put those people in geriatric units. Artley said her response is that these patients have dementia which is a physical condition. She said dementia is not a mental illness.
Stutsman said it could be overwhelming if every time a nursing home did that it wouldn’t take long for the word to get out. R. Sullivan said they might as well point out to the State that this is a huge problem waiting to happen. He said as soon as someone starts to figure out how to use it, they will all use it. Artley said in late November 2008 she received a survey form the State Ombudsmen's Office. She let them know about this issue in her response. Artley said the Ombudsmen said she had never heard of this and that she would look into it.
Artley told the Board that Johnson County is not required to fund Developmental Disabilities except for the people in ICF/MR levels of care. She said Developmental Disability (DD) is an optional diagnosis to fund. Stutsman asked how many people with DD the County is currently funding. Artley said she does not know but it is a very small part of the budget overall. She said while there is small number of DD cases, they are significantly expensive. She said overall the FY08 expenditures for DD was $555,704. Stutsman asked if that included those individuals in the ICF/MR. Artley said yes that includes everything from workshop service, out patient psychotherapy, psychiatric care, a person receiving adult daycare, and supported employment.
Stutsman asked if a change in the poverty level would have an impact on that. Artley said it might, there were three DD clients between the 200% and 250% poverty level. R. Sullivan said one thing to be careful of is to make sure that those people do not become an ICF/MR and it will cost more, so it has to be on a case by case basis. Neuzil said it is easier to phase something down then it is to cut. Stutsman said they are not eliminating the service, they are just eliminating the County paying for the service. She said the people could still get the level of service but would just have to pay for it themselves.
Artley said this is a big problem for the people on waiver services. A provider sends in an adjusted cost report in the middle of the year and the State approves it. Then the provider sends a letter with the new rate and the County has to pay the non-federal share. She said there is no control over this and it has had a tremendous impact, especially in 2006. Artley said she would like to set up another time and bring back the re-estimates for FY09 so a real strong comparison can be made and the Board can have time to think about the issues discussed today.
Artley said MH/DS is out of money, October 2008 put them under. Neuzil said Artley could return on January 12, 2009 when the Board has the next Budget meeting at 9:00 a.m. He said Claiborne will need the information beforehand to get it into the system. He said it would give MH/DS a week to follow up on questions to the Auditor's Office. Neuzil asked Artley to be prepared to present budget impacts if the County lowers the poverty level to 200%. He said at that point the Board will go through a list of questions with Claiborne.
Harney asked if the cutbacks have to be approved by the Planning Council first. Stutsman said they can make a recommendation. Artley said it is the Boards decision. Stutsman said it is a good public hearing process to lay it all out. Harney said it can’t be stretched out too long. Claiborne said MH/DS is a major part of the State form that he does and it takes at least a week or two to complete. He said February 11, 2009 is the due date for the State form which gives Artley time this month to hammer out the MH/DS budget. He asked if the Board and Artley think they will have their budget completed January 12, 2009. Artley said they have a Planning Council meeting scheduled for January 15, 2009. She asked if the Board would like to get some information from them first before the final recommendation is made. Claiborne said if the MH/DS budget could be done on January 21, 2009, it would give him several weeks to input MH/DS department in GEMS and get the State form done.
Neuzil said he still thinks it would be good to meet and get some of those questions answered and let the Board see what the budget will look like by January 12, 2009. Artley said she will have a second draft by January 12, 2009. Neuzil said that way there will be enough information to give to the Planning Council on the 15th and then the Board will follow up on the 21st. Artley said she would like to work with Claiborne to clean up the budget items that are no longer current. She said she has one number in the Chronically Mentally Ill section for an RCF/MR. She said that is an error needing correction. Artley gave another example and Claiborne said he heard that so far MH/DS is trying to stay closer to the State form. Artley said yes that is what she wants to do.
Artley said the numbers on the service matrix correlate with what the Board has to turn in to the State Auditor's Office. She said she is trying to go back to the previous format and pull everything back. She said she is doing the same thing for the billing codes. She is trying to make them all align. Claiborne said Artley has 500 to 600 line items and it is absolutely ridiculous. Artley said she has to go back and check with Guard because she was gone recently and Artley wants her input. She asked Claiborne to give her as much revenue information as possible.
Adjourned at 10:27 a.m.
______________________________________________________________________
Attest: Tom Slockett, Auditor
By Nancy Tomkovicz, Recording Secretary
Sent to the Board of Supervisors on July 21, 2009 at 12:00 p.m.