2009-10 Budget Analysis Series: Health

DMH—State Hospital Estimate Package Still Needs Improvement


In order to address concerns regarding the clarity and completeness of the budget proposal submitted each year for DMH, the Legislature adopted statutory budget language (as part of Chapter 758). The measure requires DMH to include specified information regarding the state hospital budget requests that are submitted annually to the Legislature each January 10 and at the time of the May Revision.

Historically, DMH has submitted its budget request in the form of a few summary tables and charts and several budget change proposals (BCPs). (A BCP is a proposal to change the level of service or funding for activities authorized by the Legislature, propose new program activities not currently authorized, or to delete existing programs. BCPs are prepared and submitted in a standard format.) Chapter 758 requires DMH to instead provide the Legislature with a fiscal estimate package. Generally, a fiscal estimate package combines the information contained in BCPs in a condensed format and provides additional information beyond what is typically provided in BCPs. In addition to overall requirements under Chapter 758 for information on patient caseload, staffing requirements, and OE&E, DMH’s state hospital estimate package is required to include information on the following: (1) key budget assumptions and the methodologies used to estimate caseloads, staffing costs, and operating expenses and equipment; (2) policy changes; (3) fiscal “bridge” charts showing how the budget would change relative to the budget adopted in the prior year; and (4) additional information, as necessary, to provide the Legislature with a comprehensive fiscal picture.

These requirements would make the budget information related to the state hospital system more like the budget estimates provided for other departments with caseload– driven programs. For example, DDS submits an estimate package to the Legislature for its DCs. The DDS also provides a so–called “blue book” with additional caseload and budget information to the Legislature. The DDS estimate package and other important budget information are publicly available and easy to locate on DDS’ Web site.

State Hospital Budget Request Does Not Meet All Chapter 758 Requirements

In our view, the hospital package submitted with the Governor’s January 10 budget plan does not fully meet the requirements of Chapter 758. For example, the budget documents do not provide sufficient descriptions of budget assumptions and methodologies. Figure 13 illustrates what elements of Chapter 758 we believe DMH meets, partially meets, or does not meet in the budget request submitted to the Legislature on January 10, 2009.

Figure 13

State Hospital Budget Request Does
Not Meet All Chapter 758 Requirements


Status of Compliance



Partially Meets

Does Not Meet

Overall Requirements




The estimate package shall address:




Patient caseload by commitment category




Non-level-of-care staffing requirements




Level-of-care staffing requirements




Operating expenses and equipment




Assumptions and Methodology




The estimate package shall include a statement
articulating the assumptions and methodologies used for calculating the following:




Patient caseload factors




All staffing costs




Operating expenses and equipment




Policy Changes




The estimate package submitted shall include, where applicable, individual policy changes containing a
narrative and basis for proposed and estimated costs.




Fiscal Bridge Charts




The estimate package shall include fiscal bridge charts to provide the basis for the year-to-year changes.




Legislature Needs More and Better Information

Chapter 758 required the estimate package to include certain information, but also allows the department to provide additional information as deemed appropriate to provide a comprehensive fiscal perspective to the Legislature about the state hospital system. Our review indicates that it would be helpful for the department to provide additional demographic and performance data. Below, we describe why we believe this data would be useful to the Legislature.

Demographic Information Is Limited. Minimal demographic data for the state hospital patient population is currently being made available to the Legislature by DMH. We believe that tracking and reporting additional demographic information could help inform legislative policy. For example, the aging of the state hospital population is putting increasing demands on the medical capabilities of the state hospital system. However, up–to–date information on the characteristics of the state hospital caseload, including age distribution and the major diagnosis of patients, is not currently available.

Better Reporting of Performance Needed. The DMH estimate could include the reporting of key performance information that would be useful for the Legislature to help determine how effectively the state hospital system is meeting its goals and performing its mission. For example, data on the average length of stay for patients—broken out according to their state hospital, commitment category, and major diagnosis—would allow the Legislature to track how the length of stay of patients changes over time. An increasing length of stay, for example, may be an indicator of ineffective treatment practices. Other possible performance measures are accounting for the average number of IST patients participating each day in training to regain their competency and the proportion of IST patients deemed competent to stand trial after completing treatment.

In response to federal CRIPA requirements that the state improve its care of state hospital patients, DMH is continuing to develop and implement a new centralized statewide database reporting system called the Wellness and Recovery Model Support System (WaRMSS). This new system generally allows for tracking of treatment activities and outcomes. As such, we believe that DMH’s capacity to gather and easily report performance indicators for the state hospitals will be significantly improved and thus could be incorporated into the state hospital budget estimate.

Additional Information for Comprehensive Fiscal Picture. Chapter 758 allows for DMH to provide additional information to the Legislature necessary to give a comprehensive fiscal picture of the state hospital system. At this time, for these purposes, we believe that DMH should include information in the estimate package regarding the status of CRIPA compliance, waiting lists for state hospital admissions, as well as staffing vacancies and related recruitment efforts. This information, in particular, has significant cost implications for the state hospital system. For example, poor progress on CRIPA compliance could result in additional federal actions regarding the state hospitals and increased costs for the state.

Require Further Improvement Of the Estimate Package

As noted above, DMH is not yet in full compliance with the requirements of Chapter 758 and its estimate package could be significantly improved. We therefore recommend that the Legislature direct the administration to participate in a workgroup with legislative staff to develop an improved format for its January and May Revision budget requests. This process should further identify key spending, operations, and performance information, including information from WaRMSS, that should be included in the state hospital budget package.

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