AGENDA ITEM JUSTIFICATION FOR ABOVE-BASELINE REQUEST 2-2018.PDF

Item Explanation
Public Health FY19 Request for Exception to Budgeting Guidelines and Priorities
C Number: C-86-18-053-2-00
TB Services $124,000 – Reduce the vacancy rate from 15% to 0%
A) To budget for increased supply costs we have forced a vacancy rate of 15% for this activity
(currently there are no vacancies in TB control). For TB testing, the medical norm for accurate
testing has moved from the traditional PPD skin test to a more accurate QFT test using quantiferon
to test blood. While this test has increased the lab tests, it is much more accurate and requires
only one visit and less use of practitioner time. The cost of a PPD test (lab kit only – this is exclusive
of labor) is $6.84. The QFT cost is $31.28. This increase in the cost of supplies over the last 5 years
is $282,126 (2015 outside lab costs were $566,312 and 2018 lab costs for STD were $848,438).
These added costs have been shifted to the Refugee Screening Grant, the TB grant and the
Healthcare for the Homeless Grant in prior years. Starting this year the Healthcare for the
Homeless Grant is no longer with the county, the Refugee Funds has been reduced by 60 % due
to the national restrictions on the number of Refugees being allowed into the United States and
the TB Grant is at capacity. The TB program currently is running over budget in personnel by
50.18% (December 2017 personnel expense was budgeted at $55,962 with actual expense for the
month being $84,045.74). Year to date for the first 6 months of the year we are $51,624 over
budget in personnel in TB.
These requested funds will allow the program to continue with current staff to test and treat
citizens as we are required to do by statute. If the funds cannot be allocated we currently do not
have a contingency plan to deal with this shortfall and will have to address it with reductions to
STD Control portion of clinical services. This program is currently not reaching their mandates and
further decrease of that program will see increased disease rates, longer wait times and fewer
people seen.
STD Control Services $166,000 – Reduce the vacancy rate from 15% to 5%
B) We are requesting $166,000 of funding in our STD Control program. The budget was submitted
with a 15% vacancy rate in order to balance the budget. Current numbers (December 2017) show
that we are over budget in personnel by 18.7% ($32,075.64) for the last month using current
vacancy rates. Increasing these more will increase this shortfall. While staffing budget has
remained constant in STD our testing and treatment costs as well as demand have increased.
Demand has gone up in the last 3 years from 23,473 to 31,004, a 32% increase. To deal with this
increase without increasing staffing and to serve the citizens better we have introduced ‘express
testing’ which allows a patient to have blood drawn and have lab tests done without seeing a
provider. These express testing kits have increased our lab and supplies costs over the last 4 years
$292,905 (2015 supply costs were $425,463 compared to 2018 costs of $718,368). These costs
have been absorbed through grants as were the costs with TB but those sources are now gone or
maximized. The $166,000 would allow us to maintain current services only and would not do

anything to decrease the amount of investigations of STD transmissions that we are mandated to
do that we currently are falling short on.
If the funds cannot be allocated we will need to RIF one practitioner. This will result in increased
wait times, but we will also have to limit the number of people we test to decrease our supply
cost. This will put us in violation of our mandate in STD Control. Decreased testing will increase
disease rates, prolong the current syphilis epidemic we are currently in and put our current Grants
that supplement the General Fund for these activities in jeopardy as we will miss deliverables that
they require.
Childhood Immunization $150,000
C) We are required by mandate to immunize all school aged children with four immunizations, this
requirement is for all children regardless of their insurance status or economic status. The
required vaccines include MMR, Tdap, Varicella and Meningitis. Included in this group of children
are approximately 500 high school students who we are required to vaccinate but who are ages
19 to 21. Often these are students who have been involved with the judicial system or have
language, learning or other barriers that have extended their time in high school. These students
due to age are not eligible for VFC vaccine (Federally funded Vaccine for Children) and so we must
purchase the vaccines for this, vaccines are also exempt from the 340b pharmaceutical discount.
The cost is usually near $150,000 ($322.93 per student). This $150,000 as well as the other items
being requested are tied to less expenses being able to be shifted to the immunization grant due
to increased indirect burdens and also to the increase of vaccine costs which have increased from
$609,484 in FY 2014 to $1,132,478 in FY 2017 (an 85% increase). This increase is due to the cost
of vaccines and all medical costs increases but is also due to less VFC vaccine being provided.
Currently only 87% of the VFC required is being supplied to us, the remainder is the responsibility
of the County. The majority of the increase in vaccine cost is with the MMR vaccine which
currently costs $67.55 which has risen 17% over the last four years and the Varicella vaccine which
currently costs $116.08 and has risen 21% over that same period. Items C – E all deal with
Childhood immunization and the actions required if funding cannot be acquired and are explained
after item E.
Childhood Immunization $125,000
D) Public Health is required by law to input all vaccines given into the state immunization data base
(ASIIS) within 14 days of immunization. This is the database accessed by physicians and schools to
determine school eligibility. Currently we are in violation of this requirement by 30 days. We need
two additional data entry clerks to be compliant with this and the cost is $125,000. These data
entry personnel also do the insurance verifications so that we can recoup dollars from insurance
reimbursement for the insured children who present at our clinics. These activities are currently
being completed by RNs who are more expensive and don’t have the needed time to do the
action. As we fall further behind here students will not be allowed to enroll in school as their
immunizations will not show up in the data base.

Childhood Immunization $308,000
E) In order to balance the General Fund, we have forced a 32.8% vacancy rate and planned to move
3 RNs to the Fee Fund. To date the immunization fee fund is in structural balance (revenue over
expense by $30,000 as of December 2017). Pushing $308,000 to the fee fund will put it out of
balance with current expected revenues. In FY 19 we are expecting a slight decrease in insurance
collections as several carriers are no longer going to reimburse us for the action or will be reducing
their reimbursement rates. We are requesting the $308,000 be added to the general fund budget
so that these nurses may remain funded where they currently are.
The action plan if we do not receive the additional funds in general fund will be to close the East
Valley Immunization clinic, and reduce the workforce by the associated staff. This clinic currently
services 9,450 children. These children would either need to travel to our location at 16th Street
and Roosevelt or not be immunized. Our community is currently on the edge of what would be
considered the loss of herd immunity. This loss would open the door for the return of measles,
chicken pox, mumps and other diseases into our population and put us in direct violation of our
statutory requirements.
Epidemiology $75,000
F) We are mandated to investigate 74 reportable diseases. Each year we receive around 39,000
disease reports and of those about 14,000 are for reportable diseases that we are required to
investigate (in 2017 there were 13,804) but only 47% of our mandate is reached with current staff.
We have received federal funding for the Public Health Emergency Program (PHEP) which
currently pays for 9 of our epidemiologists. Due to increases in indirect we will be short $75,000
for these positions that are supporting our general fund responsibility. We also will lose at the
end of FY18, 9 Epidemiologists and 2 data entry clerks who are paid with Federal Zika Response
Grant dollars and this funding ends at the end of that period. The $75,000 will only return us to
pre-Zika Funding response levels which will bring our response rate back down to the 40% level.
If we do not receive added funds we will have to make the appropriate cuts in the general funded
personnel as the Grant deliverables in PHEP must be met or these added funds will be lost.
Epidemiology $163,000 – Reduce the vacancy rate from 14% to 7%
G) In order to balance the budget, vacancy rates in epidemiology were increased to 14%. Currently
we are already behind our mandated service requirements, and in FY19 we will lose 15% of our
current staff who are contracted with through Zika Funding. As of December 2017 we are
currently fully staffed and therefore under the current budgeted vacancy rate of 7%. The amount
needed to return to the 7% vacancy rate which we are already far short of is $163,000.
If this funding is not allowed we will need to terminate current staff to stay within the budget.
Loss of these staff will push our response rate to mandated diseases below the 40% level.

Policy Development $343,300 – Restore funding from FY14 budget level
H) The policy work that we do in public health is responsible for ASU and the Maricopa County
Community College system going smoke free. We have been the moving force for shared use
agreements that have begun to open locked school playgrounds to communities to work to assist
with our community and national obesity epidemic. We currently are working with Correctional
Health on a smoking cessation program developed by the University of Colorado as smoking
cessation has had a direct correlation to the decrease of recidivism in jails. We are working with
community partners to further the shared use agreements with schools to increase the number
of places for families and youth to be active in their neighborhoods to work on obesity reductions.
We are also working with the Arizona Interscholastic Athletic association to develop Opioid
protocols (much like concussion protocols) to help reduce the number of high school athletes who
become addicted to opioids after sports injuries. We are also working on policy development that
will support the Governor’s Opioid Initiative. We established the policy development program in
the department for budget year FY14 at the direction of the Board of Supervisors by eliminating
positions and stripping other programs of funding to establish a fund of $759,500 to work on
policy development as this is the most cost effective form of public health. In the FY19 budget
request for activity PHPD, we have budgeted $416,200 which is mostly for personnel. These
employees work with various community coalitions to promote Public Health initiatives. The
initiatives that work on policy development such as those initiatives listed above are done by
contracts with outside contractors who have developed these in other jurisdictions and can
produce the work more cost effectively than we can with internal personnel. Due to budget
shortfalls in mandated areas we have had to strip the funding for collaborative contracts for this
activity during this budget prep cycle to $37,835. The $343,300 will restore the PHPD budget to
the original FY14 funding level, and will allow us to keep current initiatives moving.
If this funding cannot be obtained we will need to terminate these activities.
New X ray Machine in TB Program $237,775
I) The current digital X-ray system that is vital in the detection and diagnosis of tuberculosis was
purchased in 2006 at a cost of $535,700. The system is well past the warranty period and has
become prone to failure. The manufacturer no longer produces replacement parts for the
machine and when it breaks they have to search for old machines to remove parts from to repair
ours. They recommend replacement and the current quote is for $237,775.
If funding cannot be achieved we will continue as we are now until the machine can no longer be
repaired. At that time we will have to contract out for X ray services and have to request additional
funds for this activity. This is more expensive and requires the compliance of patients to go to
another facility for further tests which they may not do. Both costs and infection rates will
increase if we delay or further complicate the diagnosis work.