Public Health Department FY 2016 Recommended Budget City Council meeting June 15, 2015 Public Hearing 1

Background On June 8 th staff presented the recommend operating budget for the Public Health Department  Eliminate clinical programs: Prenatal, HIV services, DUI classes and Public Health Laboratory  Changes are driven by success of Affordable Care Act and Medi- Cal expansion  Alternate providers exist for these services  Public Health Department to focus on core public health services 2

Response to Council Questions Regarding HIV services, is CHAPcare’s approval required in order for another FQHC to locate in Pasadena  No, Federal Government (HRSA) makes determination based on need  CHAPcare has indicated it is prepared to establish HIV clinic without County of Los Angeles contracts 3

Projected Financial Gap 4

FQHC Requirements Provision of comprehensive primary medical care:  Diagnostic laboratory and radiological services;  Preventive services including: prenatal and perinatal, cancer and other disease screening, well child ser­vices, immunizations against vaccine preventable diseases, screening for elevated blood lead levels, com­municable diseases and cholesterol;  Eye, ear and dental screening for children;  Voluntary family planning services;  Preventive dental services;  Emergency medical services including coverage for hours when the center is closed;  Pharmaceutical services, as appropriate to the particular health center;  Referrals to other providers of medical and health-related services including substance abuse and mental health services;  Patient case management services including referral and follow-up and accessing eligibility for and gaining access to Federal, State, and local support and financial programs for medical, social, housing and other related services;  Enabling services including outreach, transportation, interpreter services, and education about health services availability and appropriate use. 5

Decision Process Staff is recommending and budget assumes the following timeline  July 1 or as soonest thereafter, Public Health Laboratory and Driving Under the Influence (DUI) program  September 30, HIV services including dental  December 31, Prenatal clinic City must provide 90 day transition plan for clients in HIV clinic Other considerations:  CHAPcare’s willingness/ability to step in to HIV Services  Ability to bring in alternate HIV services provider Ultimately City Council determination 6

Realigned Public Health Department 7

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Mission Statement The City of Pasadena Public Health Department is dedicated to the physical, social and mental well-being of all who live, work, learn and play in Pasadena. 9

Public Health Department Sources FY 2014 Actual FY 2015 Revised FY 2016 Recommended Health Fund$11,510,240$15,329,895$11,246,027 Total$11,510,240$15,329,895$11,246, Revenue History By Fund

Public Health Department Expenses FY 2014 Actual FY 2015 Revised FY 2016 Recommended Health Fund$13,606,509$15,495,052$12,421,109 Total$13,606,509$15,495,052$12,421, Expense History By Fund

Public Health Department Expenses FY 2014 Actual FY 2015 Revised FY 2016 Recommended Personnel$9,348,154$11,281,597$8,403,491 Servs & Supplies$2,811,671$2,638,546$2,147,477 IS Charges$1,390,761$1,574,909$1,670,804 Other$55,923$0$199,044 Total$13,606,509$15,495,052$12,421, Expense History By Category

Public Health Department Key Issues Poor financial performance of Health Fund Impact of Affordable Care Act on clinical services Realign Department mission to focus on core public health services Expand role in promoting community health Strategies Transition clinical programs to Federally Qualified Health Center (FQHC) providers Focus department resources on addressing gaps in healthcare services for underserved populations Seek opportunities to implement new programs and partnerships that promote health 13 FY 2016 Key Issues and Strategies

Financial Performance & Projections 14 Public Health Fund Fund 203 FY 2008FY 2009FY 2010FY 2011FY 2012FY 2013FY 2014FY 2015 FY 2016 Actual AdoptedEst ActualProjected Beginning Fund Balance131,812(799,762)(53,840)632,522353,771 1,035,794 1,011,177 (1,085,092) (3,062,914) SOURCES Sales Tax811,596723,742680,644710,827708,804669,575806,824650,828712,175287,930 Licenses and Permits644,195579,070713,619897,7841,003,6251,041,4141,291,3281,098,7701,346,1791,185,000 Intergovernmental-Local81,36864,587221,634213,855264,207387,282444,041790,402417,041599,168 Charges For Services653,908575,059728,880537,438537,538625,136735,3901,046,335794,169808,527 Charges For Services-Quasi Ext44,00046,90648,78249, , Federal Grants Indirect-State4,062,8024,471,4294,032,6603,684,3194,751,1435,005,5013,740,5464,768,5113,952,3495,272,524 Federal Grants-Direct ,044282,854195, ,285515,0261,075,3301,436,605 State Grant Direct452,530668,729293,671275,021275, , , , ,671306,410 State Non Grant Direct3,180,4192,341,4302,992,7442,581,9342,549,4683,362,9873,603,4034,612,0202,997,9143,963,610 Transfers In1,085,1211,077,8031,069,3021,425,2141,054,131 1,341, General Fund Contribution -1,250,000899, Other Financing Sources50, ,24077,00037, , Rental Income12,49313,57213,95918,96073,750 (14,336) 14,428 12,480 13,439 - Miscellaneous Revenue122,541404,87415,767(6,236)79, , ,958 1,391, ,960435,145 Total Revenue11,200,97312,217,19911,935,58810,748,72911,581,13713,455,20211,510,24015,329,89511,628,22714,294,919 EXPENSES Personnel8,113,7677,984,9607,418,3957,088,2926,969,363 8,132,126 9,348,15410,971,1239,441,44311,538,171 Services & Supplies2,994,6132,542,0382,707,9803,040,1592,799,368 4,085,3022,811,6711,824,0262,419,5893,039,576 Internal Services1,015,445944,279922,853899,0291,130,383 1,262,389 1,390,7611,574,909 1,670,804 Transfers , , , ,923 Total Expenses12,123,82511,471,27711,249,22811,027,48010,899,11413,479,81713,606,50914,370,05813,606,04916,304,474 Net Income(922,852)745,922686,360(278,751)682,023 (24,617) (2,096,269) 959,837 (1,977,822)(2,009,555) Adjustment Transfer to Capital Projects Fund(8,722) Ending Fund Balance(799,762)(53,840)632,521353,7711,035,7941,011,177(1,085,092)(125,255)(3,062,914)(5,072,469)

Financial Performance & Projections Public Health Fund Fund 203 FY 2013FY 2014FY 2015FY 2016FY 2017FY 2018FY 2019FY 2020 Actual Est ActualProjected Beginning Fund Balance 1,035,794 1,011,177 (1,085,092)(3,062,914)(5,072,469)(8,750,533)(12,732,295)(17,392,773) SOURCES Sales Tax669,575806,824712,175287,930292,249296,633302,566308,617 Licenses and Permits1,041,4141,291,3281,346,1791,185,0001,202,7751,220,8171,245,2331,270,138 Intergovernmental-Local387,282444,041417,041599,168608,156606,050 Charges For Services625,136735,390794,169808,527820,655832,965849,624866,617 Charges For Services-Quasi Ext Federal Grants Indirect-State5,005,5013,740,5463,952,3495,272,5244,009,6224,069,7664,151,1624,234,185 Federal Grants-Direct0474,2851,075,3301,436,6051,325,3301,125,330487,000 State Grant Direct 282, ,037217,671306,410311,006285,137278,215 State Non Grant Direct3,362,9873,603,4032,997,9143,963,6104,023,0644,083,4104,165,0784,248,380 Transfers In 1,341, General Fund Contribution Other Financing Sources Rental Income (14,336) 14,42813, ,494 Miscellaneous Revenue 753, ,958101,960435,145100,000 Total Revenue13,455,20211,510,24011,628,22714,294,91912,707,35112,634,60212,199,42212,413,695 EXPENSES Personnel 8,132,126 9,348,1549,441,44311,538,17111,740,14711,945,65812,154,76712,367,536 Services & Supplies 4,085,3022,811,6712,419,5893,039,5762,893,479 Internal Services 1,262,389 1,390,7611,574,9091,670,8041,695,8661,721,3041,755,7301,790,845 Transfers - 55, ,10855,923 Total Expenses13,479,81713,606,50913,606,04916,304,47416,385,41516,616,36416,859,89917,107,783 Net Income (24,617) (2,096,269) (1,977,822)(2,009,555)(3,678,064)(3,981,762)(4,660,477)(4,694,088) Adjustment Transfer to Capital Projects Fund Ending Fund Balance1,011,177(1,085,092)(3,062,914)(5,072,469)(8,750,533)(12,732,295)(17,392,773)(22,086,860) 15

Affordable Care Act Impacts Driving patients to Federally Qualified Health Centers (FQHCs) or ‘medical homes’  Focus on whole-person care, coordinated and integrated; Provision of Essential Health Benefits:  Emergency services/hospitalization  Maternity, newborn care and pediatric services  Rehabilitative care  Mental health services  Substance abuse outpatient care  Chronic disease management  Laboratory Services 16

Affordable Care Act Impacts PPHD’s patient population is primarily Medi-Cal or uninsured patients  Cost recovery will be increasingly difficult PPHD will see increased competition from FQHCs, Medi-Cal managed care plans and other providers  As formerly uninsured including those with pre-existing conditions get coverage  As Health plans provide Essential Health Benefits e.g. prenatal, mental health Current PPHD funding sources such as Federal Ryan White dollars will continue to diminish  LA County Board of Supervisors recognized this recently when reducing HIV/AIDS funding These issues are not exclusive to PPHD, many clinics across the country have been forced to close or change their model 17

Options PPHD could seek to become an FQHC  Would require significant investment e.g. electronic health records, billing systems  Governance restructuring  Implementation of various business/management/clinical practices  Compete head-on with other providers Transition key clinical programs to other providers  FQHCs with appropriate infrastructure  Minimize impact on clients  Seamless transition  Offer space in PPHD as appropriate  Create a bridge program for affected employees 18

Restructured Public Health Department Focus on Core Public Health Services  Disease prevention and surveillance  Childhood immunizations  Health promotion  Nutrition  Environmental Health programs  Smoking prevention  Restaurant and other inspections  Emergency preparedness  Pandemic flu  Bio and other hazards 19

20 Public Health Department Reduction of FTEs  End clinical programs by December 31, 2015  June 30, 2015 – Lab, Alcohol Recovery DUI classes  September 30, 2015 – HIV Services including dental  December 31, Prenatal Overall $3 million reduction in from FY 2015 revised to FY 2016 recommended  $2.9 million reduction on Personnel, $491,000 reduction in Services and Supplies  Internal Services charges increased $96,000  Need to be revisited given departmental reductions  Balance of $199,000 is transfer to Benefits Fund and debt service. Significant Changes From FY 2015 Budget

City provided support for impacted employees Individual meetings with Human Resources, EDD and Foothill WIB  Resume writing classes  Interview skills training Job Seeker Bootcamp  Branding & Marketing your skills  Test taking strategies  Resource Guide for 21 st century job search (LinkedIn, social media) To date: seven impacted employees transferred to other positions; five others were reinstated, three others pending, three separations – one to CHAPcare  Current number of affected employees is 23; 10 regular, 13 limited term 21

Alternative Service Providers Prenatal – CHAPcare, Dr. Eboreime and Dr. Tam all located in Pasadena Alcohol Recovery – numerous other providers in the San Gabriel Valley and adjacent cities HIV Services – maintain Pasadena as a service location. Currently exploring options with CHAPcare, conceptually:  PPHD maintains existing contracts with County of Los Angeles  Enters into agreement with CHAPcare for management services  CHAPcare covers any resulting financial loss 22

Public Health Department 23

Public Health Laboratory 24 FY13FY14FY15 (Estimated) Revenue$18,430Revenue$33,213Revenue$86,267 Expenses$313,148Expenses$323,901Expenses$344,186 Variance($294,718)Variance($290,688)Variance($257,919) California Code of Regulations, section 1075 of title 17, each local health department shall have available the services of an official public health laboratory  May be provided by contract. Of 61 public health departments in California, only 34 have their own public health laboratory  Beginning in FY15, Ryan White funds could no longer be used to pay for laboratory procedures  As clinical programs are eliminated need for the lab will diminish  Currently the State and County perform most of PPHD’s testing