2004 Consultants' Warnings To Parkland

•
H E A L T H M A N A G E M E N T A S S O C I A T E S
One Michigan Avenue Building
120 North Washington Square
Suite 705
Lansing, Michigan 48933
Telephone: (517) 482-9236
180 North LaSalle Street

Suite 2305
Chicago, Illinois 60601
Telephone: (312) 641-5007
Fax: (312) 649-6678
Long Range Planning Issues for the
100 East Broad St
Dallas County Hospital District
Suite 1400
Columbus, Ohio 34215
Telephone: (614) 464-4466
8888 Keystone Crossing

Suite 1300
Prepared for:
Indianapolis, Indiana 46240
Telephone: (317) 575-4080 The Dallas County Commissioners Court
By:
th
1015 18 Street, N.W.
H EA LTH M AN A GEM ENT A SSOCIATES
Suite 210
Washington, D. C. 20036
Telephone: (202) 785-3669
Fax: (202) 833-8932
November 2004
Kleman Plaza
301 South Bronough Street
Suite 500
Tallahassee, Florida 32301
Telephone: (850) 222-0310
180 North LaSalle Street
Fax: (850) 222-0318
Suite 2305
Chicago, Illinois 60601
Telephone: (312) 641-5007
Fax: (312) 641-6678
Long Range Planning Issues for the Dallas County Hospital District
Introduction
In May of 2004, the Dallas County Commissioners Court contracted with Health Management
Associates (HMA) to develop a “Long Range Planning and Policy Analysis for the Dallas
County Hospital District.” HMA assembled a team of ten senior staff and seven sub-contractors
to thoroughly evaluate the strategic priorities for Dallas County as they relate to the financing,
operation, clinical focus and governance of the health care delivery system for low-income
people in Dallas County. Over the course of the past six months, HMA has interacted with over
250 people (see list in the Appendices), reviewed all previous consultant reports, analyzed
financial and demographic and utilization data, met with government officials in counties
adjacent to Dallas and in Austin, participated in meetings and forums, reviewed public health
system models in comparable communities, and spent considerable time with the leadership of
the County and the Parkland Health and Hospital System to assure that our conclusions were
accurate and our recommendations were feasible.
HMA approached this project as one that would have significant consequence for the Dallas
community. We attempted to take into account the unique history, relationships, and other
cultural and environmental issues that would mean the difference between a report that was
technically correct but not likely to be implemented and one that is essentially a work plan to
take a highly regarded and vitally important health system successfully through the next
decade when there will be mounting pressures and challenges. The report that follows
documents key findings and recommendations based on the analysis of the last several months.
Additional supportive information is included in the Appendices.
HMA would like to thank the Dallas County Commissioners Court for the opportunity to have
contributed to this important initiative.
Pat Terrell, Project Manager

Doug Elwell, Finance Leader
Terry Conway, MD, Health Services Leader
Dave Ferguson
Gaylee Morgan
Jane Longo
Matt Powers
Larry Bara
Donna Strugar-Fritsch
David Fosdick
We would also like to acknowledge the contributions of our sub-contractors: Susan Greene, ESI,
Robin Herskowitz, Linda Wertz, Jon Hockenyos and Travis James, and Ann Kitchen. Finally,
we want to thank Colleen Porter and Kathryn McRay for their invaluable administrative
support.
Health Management Associates November 2004

Table of Contents
Executive Summary ...........................................................................................4
Chapter 1: What is the Current Health of Dallas County? ................................ 14
A. The Population to be Served ....................................................................................................... 14
The Dallas County Population ................................................................................................... 14
The Parkland Patient Population ............................................................................................... 16
Future Demographic Trends ...................................................................................................... 17
B. The Health Status of Dallas County ........................................................................................... 18
What is “Health Status?”............................................................................................................. 18
Health Status of Dallas County .................................................................................................. 19
Health Status of the Parkland Population ................................................................................ 20
Key Health Conditions to be Addressed .................................................................................. 21
C. The Dallas County Economic Climate and the Impact on Health Care................................ 22
Characteristics of the Dallas County Economy........................................................................ 22
Health Care and the Dallas Economy ....................................................................................... 23
D. Expenditures on Low-income Health Care in Dallas County................................................ 25
Medicaid/SCHIP.......................................................................................................................... 26
Medicare ........................................................................................................................................ 27
Tax Support................................................................................................................................... 27
Other Public Support ................................................................................................................... 27
Parkland Foundation ................................................................................................................... 28
Private Hospital Charity Care .................................................................................................... 28
E. Health Care Providers Serving Low-Income Patients in Dallas County .............................. 28
The Parkland System ................................................................................................................... 28
Private Hospitals .......................................................................................................................... 29
F. Financing Low-income Health Care in Dallas County ............................................................ 31
Medicaid/SCHIP.......................................................................................................................... 31
County Subsidies.......................................................................................................................... 31
Chapter 2: How Effective is the Public Health and Hospital System in Dallas?33
A. The Dallas County Hospital District as a System of Care ...................................................... 33
System-Wide Priorities ................................................................................................................ 33
Primary Care ................................................................................................................................. 36
Specialty Care ............................................................................................................................... 44
Emergency Care............................................................................................................................ 49
Inpatient Care ............................................................................................................................... 53
Gaps in the Current System of Care .......................................................................................... 57
Disease Management ................................................................................................................... 58
B. The Relationship of Parkland to the University of Texas Southwestern School of
Medicine ............................................................................................................................................. 63
History ........................................................................................................................................... 63
The Faculty Contract.................................................................................................................... 64
Medical Staff Leadership............................................................................................................. 68
Health Management Associates 1 November 2004

Long-Term Planning Issues ........................................................................................................ 70

Conclusion..................................................................................................................................... 71
C. The Financing of the Parkland System ...................................................................................... 71
Adequate Leveraging of Local Tax Revenue............................................................................ 72
Maintenance of Adequate Local Tax Revenue and Taxpayer Equity................................... 76
Out-of-County Care Provided By Parkland ............................................................................. 77
Operational Effectiveness of the Parkland System.................................................................. 79
Financial Management and Information Technology............................................................. 83
Contract for Medical Staff ........................................................................................................... 86
Additional Service Opportunities.............................................................................................. 89
Conclusion..................................................................................................................................... 90
D. The Physical Facilities Challenges for the Parkland System .................................................. 91
Moving Forward on a Capital Master Plan .............................................................................. 91
Next Step: A “Blue-Ribbon” Panel............................................................................................. 93
E. Potential Provider Partnerships for the Parkland System ...................................................... 94
Private Hospitals .......................................................................................................................... 94
Children’s Medical Center .......................................................................................................... 96
Veteran’s Administration/North Texas Region ...................................................................... 97
Community Primary Care........................................................................................................... 98
Other Health Care Agencies ....................................................................................................... 99
F. Governance Effectiveness Issues for Dallas County, the Dallas County Hospital
District and the Parkland Health and Hospital System............................................................. 100
Background ................................................................................................................................. 100
The Role of the Dallas County Commissioners Court .......................................................... 101
The Role of the Dallas County Hospital District.................................................................... 102
Conclusion................................................................................................................................... 102
Chapter 3: Recommendations for Long-Range Planning Priorities for the Dallas
County Hospital District ............................................................................... 103
Priorities for Parkland System Clinical Operations.................................................................... 103
System-Wide Issues ................................................................................................................... 103
Primary Care ............................................................................................................................... 104
Specialty Care ............................................................................................................................. 104
Emergency Services ................................................................................................................... 105
Inpatient Care ............................................................................................................................. 105
Gaps in the Current System ...................................................................................................... 106
Disease Management ................................................................................................................. 106
Medical Staff Relationship ........................................................................................................ 106
Physical Plant Issues .................................................................................................................. 107
Priorities for Health Care Financing ............................................................................................. 108
System Financial Strategies....................................................................................................... 108
Financial Management .............................................................................................................. 109
Priorities For Partnership Development and Expansion ........................................................... 110
Priorities for an Effective Health System Governance ............................................................... 110

APPENDICES ................................................................................................ 112
A. Project Interview/Interaction Listing

B. Maps
C. Private Hospital Data Profiles
D. Project Access, FQHCs, Free Clinics, and Public Health Departments
E. Parkland Health & Hospital System, Uncompensated & Undocumented Health Care
Analysis (Economic Projections)
F. Medicaid Reimbursement Comparisons
G. Pharmacy Issue Paper
H. Parkland Community Health Plan Report
I. Finance Deliverables
J. Revenue Cycle Report
K. COPC Assessment Report
K-1. COPC Assessment
K-2. COPC Maps
K-3. Community Clinic Profiles
K-4. Operations Plan performance
COPC Service Standards
Financial Management Tool
Care Team Roles
K-5. COPC Staffing Tool June 2004
MGMA 2002 Benchmarks
K-6. EPIC Newborn Appointments COPC

EXECUTIVE SUMMARY
The Approach
Health Management Associates (HMA) approached its task of developing long range planning
issues for the Dallas County Hospital District in several stages. First, the current situation was
documented. What is the population of low-income people that are or most likely will become
patients cared for by the Parkland Health and Hospital System? Where do they live and what
are their health care needs? What are the demographic and economic trends that will impact
this population in the future? What is spent on low-income health care services? Who are the
health care providers delivering that care? Finally, what are the strategies in place to finance
this delivery system?
The second stage of the analysis focused on the ability of the current health care delivery system
to most effectively meet the challenges posed by the growing low-income population. Is
Parkland functioning as a seamless system of care, utilizing every level of service delivery
appropriately? Are there gaps in the system that result in either operational inefficiencies or
less than optimal health outcomes? Is the relationship between Parkland and the University of
Texas Southwestern School of Medicine resulting in high quality and cost-effective clinical care
and are there longer-term concerns that need to be addressed related to the synergy between
the two institutions? What are critical financing strategies that need to be implemented to
maximize the impact of the County contribution to health care? What is the quantifiable impact
of out-of-county use of Parkland’s health services? What are the capital investment issues that
the system faces both now and in the future? Are there creative partnerships that could be
created to strengthen the overall health care “safety net” in the community? Finally, what are
the key issues related to the assurance of a strong, accountable and effective governance for
publicly supported health services in Dallas County?
Over the past six months, HMA has attempted to answer all of these questions. We have
interacted with more than 250 government officials, health care and business leaders, civic and
advocacy group representatives, doctors, patients, and other front line clinical and

administrative staff. We went on inpatient rounds and observed in the Parkland clinics and
Emergency Department. We reviewed all recent consultant reports related to the Parkland
system. We attended meetings organized by key business, civic and advocacy constituencies.
We analyzed financial, demographic and health care utilization data. We traveled to all of the
surrounding counties and to Austin to talk with relevant officials about the issues being faced in
Dallas. We worked with senior staff at Parkland, at the University of Texas Southwestern
(UTSW), with private hospitals and other key components of the formal and informal network
of institutions and individuals committed to providing health care services for the people of
Dallas. This Report is the cumulative result of all of these efforts.
Key Findings
Although these findings are addressed in much greater depth in the body of the Report, the
following information related to the delivery of health care services for low-income people in
Dallas drives the ultimate recommendations for planning priorities for the Dallas County
Hospital District:
• There is an unusual and exemplary level of interest in and commitment to assuring

health care services for low-income people in Dallas County. HMA found that the
expression of support for continuing to assure access to health care services for the
residents of the community was consistent and universal. While it was clear that those
services should be provided in the most cost-effective way possible, there was an
unwavering sense from the business, health care, civic, religious and advocacy
communities that those services needed to be provided. In fact, it was a measure of
pride for the Dallas community.
• Dallas County is a growing and changing community. The population in Dallas

County grew by 20% between 1990 and 2000 and that growth continues, largely due to a
near doubling of the Hispanic population during that same period. The County is also
economically diverse, with both a higher per capita income than Texas as a whole and a
higher proportion of low-income individuals, now one in three residents.
Approximately 25% of the non-elderly population of Dallas County is uninsured, a
statistic that is not likely to improve as the economic correction now underway is due

largely to growth in the service sector, which is traditionally less likely to provide health
insurance benefits.
• The demand on the Parkland Health and Hospital System will only increase. Growth
in both total population and the uninsured will likely result in further demand on the
Parkland system for health care services, particularly by chronically ill adults whose care
is disproportionately expensive. The Parkland system now accounts for about half of all
of the uncompensated health care services delivered to residents of Dallas County.
Several private hospitals in the community have experienced significant increases in
Emergency Department visits by people who are either uninsured or covered by
Medicaid. Two Federally Qualified Health Centers (FQHCs), Project Access and a
growing number of free clinics located throughout the County have attempted to meet
some of the need, but the Parkland is still the linchpin for the entire “safety net” in
Dallas County.
• Dallas County is providing a significant contribution to health care for low-income

people but that contribution is not fully leveraged. The total expenditures on health
care services for low-income people in Dallas County—from all sources—totaled more
than $1.7 billion in 2002. Of that amount, the County subsidy to the Dallas County
Hospital District was approximately $311 million. While the County contributes more
money to health care services per capita than most other local governments around the
country, it has been less successful in leveraging that contribution to generate the federal
matching dollars for which it is eligible. Today, Dallas County leaves $150 million
unmatched.
• The Parkland Health and Hospital System is a major community resource. Parkland
is widely considered to be one of the best public health care delivery systems in the
nation. Through its partnership with UTSW, it provides high quality clinical services. It
has made enormous strides in operating cost-effectively and in generating revenue. It
has attempted to rationalize care by treating people in community-based settings before
they get sick enough to need more expensive services at the hospital. It is the trauma
resource relied upon by the entire greater Dallas community. The Parkland system has
had a significant impact on the health status of the overall Dallas community,
particularly in the area of maternal and infant health care.

• Specific strategic initiatives should be undertaken to assure that Parkland operates

effectively in the face of growing pressures. There are significant organizational,
financial, clinical and policy issues related to both the current and future operation of
the health system that must be addressed if Parkland is to function effectively in light of
mounting demand for its services. Hard decisions will need to be made involving the
health system’s leadership, its Board, its medical school partner and the broader
community to ensure that the system will be able to continue to function at a high level
of both quality and efficiency. The recommendations contained in the report address
these specific issues.
Recommendations
The list of recommendations that follow are explained more fully within the Report.
Priorities for Parkland System Clinical Operations
1) Make the recruitment of a Chief Operating Officer a priority for the Parkland system.
2) Begin, in partnership with the University of Texas Southwestern (UTSW), a process to

reassess policies and procedures and allocation of clinical resources that were developed
to facilitate teaching in Parkland but now may inhibit effective operation of the health
system.
3) Address operational problems that discourage Parkland patients from staying in the
system when they become insured.
4) Initiate serious and specific discussions with other health care providers to identify areas
of potential collaboration.
5) Make the improvement of access to the COPC clinics a primary focus of the Parkland
system.
6) Better integrate the health services delivered at the COPCs with the specific needs of the
communities that they serve by coordinating with other agencies, assessing the potential

for expansion or contraction of clinics based on population growth or movement, and

maintaining the ongoing role of community advisory boards.
7) Ensure that the COPCs are seen as an essential component of the continuum of care by
the entire Parkland system, including the clinical leadership. Issues of referrals,
admission procedures, policies, medical staff communication and resource allocation for
the COPCs must be viewed for their impact on every aspect of the Parkland system.
8) Initiate an immediate and thorough assessment of the clinical resources and space
needed to provide accessible specialty outpatient services for the patients who depend
upon the Parkland system for that care who otherwise would utilize the Parkland
Emergency Department (ED) or be admitted for services that could have been provided
in specialty clinics.
9) Develop a plan to reallocate or, where necessary, expand resources dedicated to certain
specialty areas where there is a current deficit.
10) Develop a referral system, based on sound clinical guidelines, that will assure ease of
access to specialty services, the appropriateness of referrals to specialty care, and return
to primary care after the specialty consult to avoid misuse of scarce resources.
11) Explore the potential for partnering with other hospitals and/or physician groups to
expand accessibility to specialty outpatient services, particularly in less expensive and
more accessible community-based settings.
12) Initiate a major overhaul of the Parkland admissions processes, specifically addressing
the unnecessary logjam in the Parkland ED.
13) Develop an effective referral system to allow ED physicians to send patients needing
ongoing care to COPC or specialty clinics.
14) Explore the potential for establishing Observation Bed capacity adjacent to the ED to
minimize unnecessary admissions into the hospital.
15) Begin a review of clinical policies that may adversely impact efforts to prevent
unnecessary return visits to the ED and may assist in efforts to develop system-wide
disease management protocols.

16) Establish bed control as an institutional priority, building on recommendations from

previous consultant reports and involving clinical as well as administrative leadership.
17) Rationalize the current logjam in the operating rooms by reassessing the management
structure (including reassigning case managers who had been replaced by residents),
moving forward on the construction of the Ambulatory Surgery Center, and exploring
the potential for an interim strategy for moving outpatient surgeries into a temporary
location at another institution.
18) Initiate a process, with clinical leadership in OB/Gyne, to restructure the inpatient units
assigned to Labor and Delivery to assure the most effective utilization of all inpatient
beds while, at the same time, maintaining the protocols that have resulted in such
impressive outcomes.
19) Investigate the potential for immediate conversion of unused space within Parkland to
expand the capacity for rehabilitation services at Parkland, allowing for the retention of
current paying patients who are now being sent to other institutions.
20) Develop a comprehensive plan, perhaps in connection with the VA or other providers,
for access to long-term care for Parkland patients.
21) Implement a disease management approach throughout the Parkland system, targeting
those chronic conditions (i.e., diabetes, asthma, hypertension) that have the greatest
impact on Parkland resources and its patients.
22) Begin to develop a new Master Affiliation Agreement between the Parkland and UTSW
that will reconfirm the importance of the relationship and will address medical
leadership, operational issues related to the teaching model, future approaches to cost
reimbursement, and long-term planning issues which will impact both institutions.
23) Initiate discussion now between Parkland and the Dallas County Hospital District about
the development of a Master Capital Plan for the Parkland system.
24) Determine capital project priorities for the current system that will either assure greater
efficiency or allow for the generation of increased revenue. Priority areas should include
the construction of the Irving COPC and the Ambulatory Surgery Center, and the

renovation of existing space for the establishment of increased rehabilitation capacity

and observation beds adjacent to the ED.
25) Establish a “blue ribbon panel,” appointed by the Dallas County Court of
Commissioners and the Dallas County Hospital District, made up of key health care,
civic and business leaders. This panel would be charged with overseeing the
development, with Parkland leadership, of a Master Capital Plan for the system,
including the scope of and financing for a facilities replacement strategy for Parkland
hospital.
Priorities for Health Care Financing
1) Leverage available Dallas County funds through a variety of special financing

mechanisms, including the following. It is important to note that the leadership of the
Court and the support of the local business community will be critical to garnering State
support for these efforts.
• Take advantage of additional Upper Payment Limit (UPL) payments by

increasing Parkland’s charge structure. (Estimated impact = $ 16 million
currently, although further data analysis may lower that figure)
• Secure a federal waiver for Medicaid to cover the costs of prenatal care for
undocumented immigrants. (Estimated impact = $5 to $7 million)
• Increase Medicaid payments to Parkland and UTSW physicians.
• Secure increased Medicaid managed care rates through risk adjustment and/or
increasing the base rate on which the managed care rates are set. (Estimated
impact = $5.6 million)
• Utilize the Upper Payment Limit (UPL) capacity of other private hospitals in
Dallas County that serve large numbers of Medicaid and uninsured patients.
(Estimated potential= $225 million; $105 million if Children’s is excluded)
2) Explore the creation of a 501 ( c) (3) entity to help fund charity care at Parkland and
other organizations in the community.

3) Work with the counties contiguous to Dallas and the State to establish a regional
trauma network that would help finance trauma care provided by Parkland to out-of-
county patients by leveraging current County Indigent Health Care Program (CIHCP)
expenditures. (Estimated impact = $10 million)
4) Convert Parkland’s COPC clinics to Federally Qualified Health Centers (FQHCs).

(Estimated impact = $9.3 million)
5) Carefully evaluate new service opportunities for their potential to be successful given
Parkland’s demographics and payor mix. These include rehabilitation, long-term care
and psychiatry.
6) Ensure that Parkland has a long-term strategic business plan in place that reflects the
collective input of the operational, financial and medical leadership. The strategic plan
should be supported by a long-range capital plan and an information technology (IT)
plan. All of these documents are needed to help the Board make decisions based on the
best available information and the long-range goals of the organization.
7) Resolve the current FY2005 faculty contract between Parkland and UTSW and view it as
a transition agreement, beginning immediately to negotiate the contract for FY2006
based on covering appropriate costs, verifiability, and adequate payment for all clinical
service expansions.
8) Continue to build on revenue cycle improvements by increasing conversion of patients

to funded sources, improving time-of-service collections and implementing a stronger
denial management and collections strategy. (Estimated impact = $6 to $8 million).
9) Begin to consider the mutual benefits of a combined revenue management entity that
combines the hospital and the medical school revenue management processes, including
medical records, billing and collections.
Improve the position of the Parkland Community Health Plan by reducing
administrative costs to the industry standard, reducing payment rates to the Medicaid
rate, and reducing payments for non-participating providers. (Estimated impact = $8.2
million)

10) Ensure that Parkland is positioned to take advantage of pharmacy opportunities

afforded by the Medicare Modernization Act (MMA), including the discount card
program, low-income subsidies, and mail order, potentially through a partnership with
the VA Hospital. (Estimated impact = up to $11.7 million, not including mail order).
Priorities For Partnership Development and Expansion
1) Initiate discussions with the leadership of private hospitals in the Dallas community to
determine the potential areas of collaboration for current and future health services
provided for low-income residents of the County including, but certainly not limited to:
support (financial or service) for existing or expanded COPCs, collaboration on the
provision of community-based specialty outpatient services, joint development of
service lines (i.e., rehabilitation services), and the delivery of tertiary services for
Parkland patients.
2) Develop expanded collaboration with Children’s Medical Center, particularly focusing

on: enhancing access into the COPC clinics for patients coming to the Children’s ED for
primary care; collaborating on expanded community-based pediatric specialty care
access; exploring the potential of co-locating Children’s physicians in COPC facilities;
and better coordinating facilities and support service planning on the medical center
campus.
3) Enter into serious discussions with the Veteran’s Administration Hospital system in
Dallas to explore potential partnerships in such areas as: participating in the VA’s mail
order pharmaceutical program, one of the most effective in the country; connecting to
the VA-affiliated network of nursing home providers and contracting with its home
health services, both efforts to assure that patients do not stay in inpatient beds
unnecessarily; entering into an agreement whereby the VA would contract with the
COPCs for primary care for its veterans; and planning for a collaborative approach to
mental health services.

Priorities for an Effective Health System Governance
1) Ensure that the roles and responsibilities of the Dallas County Commissioners Court and
the Dallas County Hospital District be clearly defined and duplication should be
eliminated whenever possible.
2) Empower the Dallas County Commissioners Court to appoint a civic “nominating

committee,” made up of health care, business, civic and community leaders, to screen
potential candidates for the Dallas County Hospital District for skills and expertise
outlined in a clear job description for Board membership. This committee would
present a slate of a number of candidates that they have deemed to be “qualified” from
which the Court would select the Board’s membership. This process would go far in
assuring that the members of the District Board were committed, skilled and as
unaffected as possible by political pressure, real or perceived.

CHAPTER 1: WHAT IS THE CURRENT HEALTH OF DALLAS COUNTY?
A. The Population to be Served
In order to plan for the delivery and financing of health care services for low-income people, it
is imperative that the target population is fully understood. Where are the current and
developing communities of people who will need health care services subsidized by the public
sector? What are their ages and ethnicities and health conditions? Do they have access to other
health care services? What are the demographic trends for these indicators? These questions
need to be addressed to fully comprehend the long range planning issues for Dallas County, the
Parkland Health and Hospital System and the broader community.
The Dallas County Population
The Dallas area is growing at a rapid pace. The population of the Dallas Metropolitan Statistical
Area, comprised of Dallas County and its surrounding counties, increased by nearly a third
between 1990 and 2000. Dallas County is growing too, but at a slower rate. An estimated
2,283,953 persons lived in Dallas County in 2002. Census data indicates 20 percent growth in the
County between 1990 and 2000 and continued expansion through 2002. Demographers expect
Dallas County’s population to continue growing for decades to come.
Dallas County is slightly younger and more racially diverse than Texas and the U.S. as a whole.
It has proportionally more children less than 15 years of age and fewer adults over 65 years of
age than does the State of Texas or the nation. Data from the 2000 census indicates that non-
white residents make up 55 percent of the County’s population. As Table 1 shows, Hispanics
are the fastest growing segment of the population, more than doubling between 1990 and 2000,
while the number of people in the “other” racial/ethnic group (Asians, American Indians, etc.)
and the African American segment also grew at the same time that the County’s white
population decreased.

Table 1
Percentage Change in Dallas County Population by
Race/Ethnic Group 1990 to 2000
White -10%
Hispanic +110%
African American +25%
Other +73%
Total +20%
Dallas County’s overall high per capita income masks a wide disparity in income distribution. It
has both a large number of wealthy residents and a large portion of poor residents. In 1999,
household and per capita income for Dallas County residents were higher than in Texas or the
U.S., but its median family income was lower than that of the rest of the country. This appears
to result from the fact that Dallas County has a larger portion of higher income individuals
living in non-family households. In Dallas County, family households make up a slightly
smaller portion of the population than in Texas or the rest of the country.
Despite the County’s higher per capita income, low-income individuals (those with incomes
less than 200 percent of the Federal Poverty Level) make up a larger portion of the population
than in the U.S. One in three persons in Dallas County is considered to be “low- income.” Low-
income persons live in all parts of the County and make up a substantial portion of all of Dallas
County’s twelve service areas (as defined by the Dallas County Hospital District). In the
northern part of the County, the service area with nearly twice the County’s average per capita
income, one in five persons are still considered low- income. In all other service areas, low-
income persons make up an even larger portion of the population. The three service areas with
the highest proportion of low-income individuals are South Dallas, West Dallas and South Oak
Cliff.
Statistics on health insurance coverage indicate that 25 percent of the non-elderly Dallas County
population did not have health insurance in 1999. National data indicate that Hispanics have
the highest rates of un-insurance, followed by African Americans. Thus, Dallas County, with
growing Hispanic and African-American populations, can expect to see the current level of un-
insurance increase. Because Medicare provides the majority of health benefits to senior citizens
and Medicaid and the State Children’s Health Insurance Program (SCHIP) to predominately

pregnant women and children, the group with the highest rates of un-insurance is non-
pregnant adults between the ages of 18 and 64.
The Parkland Patient Population
The patients that utilize the Parkland System and those likely to use Parkland in the future can
be referred to as the Parkland target population. In general, the Parkland target population is
low-income, uninsured and is predominately Hispanic or African American. Data on Parkland
patients show that these characteristics vary by the way in which they access health care
services.
For example, a greater proportion of white patients visit the Parkland Emergency Department
(ED) than come to the hospital as inpatients or are patients of the Community Oriented Primary
Care (COPC) clinics (although still only one in five patients). Inpatients are predominately
Hispanic, while COPC patients are most likely to be Hispanic or African American. Reflecting
the large volume of obstetric patients at Parkland, inpatient admissions are nearly twice as
likely to be for a woman as for a man. ED patients tend to be neither younger nor older, with
three out of four between 18 and 49 years of age. Again as a result of the large volume of
obstetrical cases, one in four inpatient admissions is for a baby and 43 percent are for 18 to 39
year olds. These ages are significant as it is the 18 to 64 year old range that is most heavily
uninsured.
As Table 2 shows, the Parkland ED has a higher portion of self-pay patients as compared to
inpatient or COPC patients. Inpatient visits are most likely to be reimbursed by Medicaid or
SCHIP and COPC visits are evenly split between Medicaid/SCHIP and self-pay or charity.
Table 2
Percent of Parkland Encounters
by Payor Source
ED Inpatient COPC
Medicare 8% 8% 10%
Medicaid/SCHIP 17% 62% 39%
Self-pay 67% 22% 38%
Other 8% 7% 13%

Future Demographic Trends
In twenty years, it is predicted that Dallas County will be appreciably older and more Hispanic.
These two demographic trends will have a major impact on the Parkland target population and
on the Parkland health care system. It will impact scope of services to be provided, location of
clinics, connections for support and specialty services, and ability to generate revenue to cover
the cost of the delivery of care.
Substantial growth in the Hispanic population is expected to continue. Estimates from the Texas
State Data Center indicate that the Hispanic portion of the County’s population could grow by
170 percent between 2000 and 2020, with further growth over the subsequent two decades. This
population, which represented 30 percent of the residents of Dallas County in 2000, is expected
to comprise 38 percent of the County’s population in 2010, 47 percent in 2020, 55 percent in 2030
and 63 percent in 2040. Much of this growth will be among the young under 19 and among
adults over 45. It should be clear that this growth is not only an issue of undocumented
residents (whose growth is relatively flat) but also of a new generation of Hispanic Americans
born in the U.S. and the County. The Parkland system, and Dallas County, will need to plan for
an effective approach to caring for the health care needs of this population and, as a greater
proportion of Hispanics are uninsured, there will be an increasing need to find the revenue to
pay for that care.
The aging of Dallas County, like the rest of the country, has further implications for the make-
up of the Parkland target population. Even in the lowest population growth scenarios from the
Texas State Data Center, the portion of Dallas County residents who are over 45 years of age,
currently 27 percent, will grow to 41 percent in 2020 and 45 percent in 2040. If Parkland
continues to only capture the uninsured population of adults who have costly chronic health
care problems without also attracting patients in the growing group over 65 years of age, the
system could be crippled by the cost of this treating this population of adults without
experiencing the benefit of reimbursement generated from paying Medicare patients.
Understanding this population growth should direct the development of resources to both
effectively manage those patients that Parkland will be most likely to care for as well as
maintaining those patients in the Parkland system when they reach their 65th birthdays.

B. The Health Status of Dallas County
What is “Health Status?”
“Health status” is the level of health of an individual, group, or population as assessed by either
objective indicators or by more subjective measures such as data on how individuals perceive
their own level of health. These perceptions may include the range of manifestations of disease
in a given patient population including symptoms, functional limitations, and effect on quality
of life. Improving health status should be the basis for designing the types and volume of health
services in a public health system like Parkland. Health status should also be a leading indicator
of the effectiveness of a public health system.
Although health status is a very useful basis for projecting long term needs of the Parkland
health system, several provisos should be recognized. There are certain difficulties that are
encountered when describing health status of a community or population. Much of the
information that is available to describe health status comes from reported data garnered from
birth and death records and reportable infectious diseases. While this is very useful, it may
obscure helpful insights from a health care planning or evaluation perspective. For example,
most persons with diabetes are likely to die from cardiovascular disease while the chronic and
treatable condition of diabetes may never be noted. There are also selected surveys and
registries that contain information on specific conditions, although the list is not exhaustive. In
addition, the data is often from databases on very large populations and it can, at times, make it
difficult to examine even a very large neighborhood or ethnic population in a useful way.
Finally, the population of Dallas is certainly not a static phenomenon. It has grown and will
continue to grow in a way that will impact health status. Planning based on a snapshot taken
today is likely to be faulty. The last ten years have seen a remarkable growth in Dallas County,
particularly due to immigration and largely by persons of Mexican origin. To a much smaller
extent, the growth of the Asian, Pacific Islander, and American Indian population has increased.
Anticipating the change in health status due to continued immigration is important. Immigrants
initially tend to have better health status than natives of the United States. However, as time is
spent in the U.S. and adoption of certain unhealthy lifestyle behaviors increases, the immigrant
populations develop more chronic illness and health status worsens.

Health Status of Dallas County
Dallas County residents are, as compared to similar counties and to the nation as a whole,
relatively healthy. For example, the prevalence of chronic conditions in Dallas County in 2001
compares favorably with the U.S. and Texas for the four conditions of diabetes, asthma, high
blood pressure, and high cholesterol (2002 Dallas County Health Checkup). However, several
health issues are worthy of note. In 2002, the Health Resources and Services Administration of
the US Department of Health and Human Services (HRSA) compared Dallas County to other
counties nationwide that were similar in size and socio-demographic features. HRSA ranked
Dallas County death rates for colon cancer, coronary heart disease, homicide, lung cancer,
motor vehicle injuries, stroke, suicide and female breast cancer as unfavorable relative to peer
counties. Pediatric asthma and diabetes hospitalizations are higher than the rest of Texas. It is
notable that many of the conditions that are unfavorable within Dallas are amenable to
prevention or management by medical care in such a way that death, disability and cost are
favorably impacted. When asked, Dallas County residents ranked their health as very good or
excellent as often as residents of Texas but less often than residents of the U.S. The average life
expectancy for Dallas County residents is unfavorable, being slightly worse than the U.S., and
considered unfavorable when compared to similar counties by HRSA.
The statistics for reproductive health in Dallas County are noteworthy for the positive picture
they present. Neonatal and infant mortality rates in Dallas County are impressively low
compared to the U.S. This is even more striking when the comparison is targeted to Parkland’s
patients.
Table 3
2002 Infant/Neonatal Mortality (Rate per 1,000 live births)
Infant Mortality Neonatal Mortality
Dallas
Race/Ethnicity U.S. U.S. Parkland*
County
All Births 7.0 6.6 4.7 2.7
White 5.8 5.3 3.9 2.9
African – Am. 14.3 11.8 9.4 5.2
Hispanic - 5.7 3.8 2.4
Source: PHHS and National Center for Health Statistics
*For live births to women with prenatal care in PHHS system.

Health Status of the Parkland Population
Although patients from every community in Dallas County are served by the Parkland system,
the great majority of patients live in communities that are heavily populated by minorities and
are of low socioeconomic status. (See maps in the Appendices). The health status of these
communities is usually significantly worse than the rest of the county and contributes
negatively to overall community health status. However, the impressive reproductive health
statistics discussed above show that health status can be improved by planning and targeted
programs. The effort of a systematic, population-focused program based at Parkland, Women’s
and Infants Specialty Healthcare (WISH), has improved the outcomes of pregnant women and
their newborns from these same communities and populations. The benefits are great enough to
improve the overall community’s infant mortality rate.
The benefits seen in infant mortality are not enjoyed by all of Parkland’s service lines. Chronic
illnesses are more prevalent in the communities in which Parkland has located its COPC clinics.
For example, the South Oak Cliff neighborhood has a prevalence of high blood pressure that is
52 percent higher than Dallas County. Diabetes is 43 percent and stroke is 42 percent more
common. The number of residents of Oak Cliff that suffer from asthma is 82 percent higher than
for the overall population. Although the numbers differ in each community, the likelihood of
finding excess chronic illness is related to the percentage of poor and minority persons who live
in the community (Source: National Research Corp. Market Guide, 2001).
This same disparity in health is seen in the death rates for these communities. Heart disease is
the number one reason for death in Dallas County, as it is throughout the U.S. However, age
adjusted figures from 2001 reveal markedly elevated deaths from heart disease in South Oak
Cliff compared to the rest of Dallas County (331 versus 231, per 100,000 of population). Cancer,
stroke, HIV/AIDS, kidney disease, respiratory conditions and homicide are notable as causes of
excess deaths. Although impressive community gains have been made, rates of infant mortality
and low birthweight babies are higher in areas that are predominantly African American.
The excess deaths and increased prevalence of chronic illnesses are related. This is true not only
for the population that Parkland serves, but for the whole United States. It has been noted that
most of the health care delivered in the nation is related to chronic illness. More than 75 percent

of the money spent for health care in the U.S. is for persons with a chronic illness. (A Portrait of
the Chronically Ill in America, 2001: Robert Wood Johnson Foundation). High blood pressure,
diabetes, elevated cholesterol, along with smoking, are at the root of premature heart disease.
The disparity in the health of poor and minority populations is due to a higher level of chronic
illness. There may be some genetic reasons for these disparities. For example, for the same level
of obesity, African Americans are more likely to develop diabetes than whites. However, the
clear consensus is that the major factors causing these disparities are related to poverty itself,
decreased access to care, cultural and communication barriers, and unequal treatment within
the medical system.
Key Health Conditions to be Addressed
The growth of Dallas County is largely due to growth in the Hispanic population. While the
first generation of immigrants is healthier than the general population, in time their health
status approaches that of the native population. In other words, chronic illness is likely to
increase in the County. It is recognized that Hispanics of Mexican origin have a rate of diabetes
that is twice the general population (Office of Minority Health, CDC 2003.) This condition leads to
heart disease, kidney failure, amputations, blindness, and excess deaths.
In addition to increased diabetes, the African American population suffers disproportionately

from hypertension and heart disease. The excess deaths from stroke are due to elevated
hypertension as is an increase in kidney failure. In addition, asthma and HIV/AIDS are higher
in the African American community. Cancer of the prostate and colon are higher in this
population as well. Infant mortality remains higher in African Americans in Dallas County as it
is in the United States. The conditions above are chronic and have demonstrated interventions
that reduce suffering and death as well as reduce total health care costs. If the Parkland Health
and Hospital System is organized and operated as an integrated continuum of care to address
these conditions, the health of the community of Dallas County can be improved over time.
Several health service targets have the potential to become problem areas if current efforts are
not maintained and strengthened. One such area is immunizations. The immunization rate in
Dallas County is below state and federal standards (Beyond ABC: Growing Up in Dallas County,
2002). This situation puts the residents of Dallas County at risk for epidemics that can be

avoided. Further, as the Hispanic population begins to acquire the negative lifestyle behaviors
of other Americans, the impact on prenatal and other reproductive care could be significant and
there could be a decline in maternal and child health indicators. It will be important for the
Parkland system to remain vigilant about assuring the quality of its maternal health approach,
an approach that currently ranks as one of the most effective in the nation.
C. The Dallas County Economic Climate and the Impact on Health Care
Characteristics of the Dallas County Economy
The population that health systems serve is largely driven by the economic health of the region.
(See a full discussion of the Dallas economic climate and uncompensated cost pressures in the
Appendices). The scope and quality of a local health system has a strong relationship with the
number and types of jobs supported by the local economy. The Dallas area economy has
followed many trends that the national economy has experienced over the last decade. This has
been characterized by strong growth during the 1990s, a substantial drop off in economic
growth in the last quarter of 2001 and in 2002, and continued urban and suburban migration
patterns. The Dallas economy is a diversified economy. The high-tech sector has been a leading
industry in the region’s economy, in addition to healthcare and the service industry.
Figure 1
D a lla s A r e a In d u s t r y C o m p o s it io n
M a n u f a c tu r in g 1 0 % T r a d e , tr a n s p o r ta tio n , u t ilit ie s
22%
C o n s t r u c tio n 5 %
G ov ernment 12%
In f o r m a tio n 4 %
O th e r s e r v ic e s 4 %
F in a n c ia l a c t iv itie s 9 %
L e is u r e & h s o p ita lity 9 %
P r o f e s s io n a l & b u s in e s s
E d u c a t io n & h e a lt h s e r v ic e s
s e r v ic e s 1 5 %
10%
Source: Texas Workforce Commission, Texas Monthly Employment Review by MSA, August 2004

Dallas area employment grew consistently through the 1990s – typically averaging
approximately 4 percent payroll growth, until a substantial downturn in 2001. This sharp
downturn was followed by continued sluggish quarters until the past few quarters showed
increases. Top private employers from the Dallas area show the strength and diversity of the
economy and the significant presence of the service economy. Nationally, job growth over the
past decades has been driven by the service and retail sectors. Specific job types that have
driven the service and retail sector growth include leisure and hospitality, health care, social
service, and retail store workers. For many of these jobs, health insurance coverage has eroded
or been eliminated over time. Services approach half of the nation’s current gross domestic
product relative to about a quarter of the nation’s gross domestic product in the 1960s. Durable
goods continue to comprise a smaller portion of the nation’s gross domestic product.
The value of Parkland’s annual economic activity to the region is clear. The hospital system’s
total impact generates $1.3 billion in total output, $635.6 million of which is employee wages.
The Parkland system directly and indirectly supports 13,200 full and part-time local jobs.
Health Care and the Dallas Economy
Public health care systems have a unique perspective regarding the relationship of economics
and the workforce to health care delivery and the community. The demand for public sector
health care services is largely a function of access to private health insurance. As a result,
changes in local economic activity, overall employment, benefits provided by local business,
and the cost of individual health insurance to a large extent determine changes in demand for
publicly delivered health care services. This relationship is especially true over an extended
period of time.
National statistics (Holohan, Kaiser sources) begin to tell the story of how public providers feel
the impact of an economic downturn:
• Over 80 percent of the uninsured came from working families in 2002 – with 70 percent
of families having one or more full-time workers and 12 percent part-time workers.

• 64 percent of the uninsured have incomes less than 200 percent of the federal poverty
level. Between 2000 and 2003, approximately 75 percent of the increase in the uninsured
came from adults with incomes less than 200 percent of the federal poverty level.
• 44 percent of uninsured workers were employed by businesses with fewer than 25

workers. Between 2000 and 2003, the workforce moved from large and medium sized
firms to small firms where in which the likelihood of employer-sponsored insurance was
lower and uninsured rates were higher.
• 40 percent of the uninsured in 2002 were adults between the ages of 19 and 34. About 60
percent of the growth in the uninsured between 2000 and 2003 occurred among young
adults.
• Over half of the growth in the uninsured between 200 and 2003 was in southern states.
• 8 states implemented freezes in SCHIP during 2003 and 2004. As a result, SCHIP
enrollment fell for the first time, largely due nationally to program reductions in Texas.
Figure 2

The uninsured have a particularly significant effect on safety net providers – primarily hospital
Emergency Departments and clinics serving low-income patients. The Parkland Health and
Hospital System is the primary provider of these services for Dallas County. As Dallas County’s
only public and tax-supported hospital, Parkland is the leading provider of uncompensated
care for the community. In 2002, Parkland provided over $410 million in uncompensated care
(charges based on charity care and bad debt). This represents nearly 50 percent of all
uncompensated care provided by Dallas County acute care hospitals. From 1998-2002,
Parkland’s total uncompensated care charges increased 33 percent or a compound annual
growth rate of 7.3 percent.
The undocumented are a noteworthy component of uncompensated care costs for the Dallas
community. It is estimated that approximately 20 percent of uncompensated Parkland health
care is provided to undocumented persons (emergency and non-emergency treatment), a figure
consistent with other published studies. However, this percentage is likely to remain fairly
static over the next ten years. For example, the ongoing overall disparity between the Mexican
and U.S. economies suggests that the U.S. will continue to be viewed as the land of economic
opportunity, especially in light of domestic trends such as greater female labor force
participation, a shortage of blue-collar workers in the trades, and the general aging of the
population. All of these factors would suggest greater in-migration. On the other hand, border
security has been heightened in the wake of 9/11 (both in terms of policy and enforcement),
which will tend to dampen movement of undocumented persons northward. As a result, the
percentage of uncompensated care attributable to undocumented persons is likely to be held
constant over the forecast horizon.
D. Expenditures on Low-income Health Care in Dallas County
In 2002, the most recent year for which complete data is available, more than $1.7 billion was
expended for low-income health care in Dallas County. Table 4 below details expenditures by
major funding source (see Appendices for a more detailed discussion of expenditures for low-
income care).

Table 4
Expenditures for Low-Income Healthcare in Dallas County (2002)
2002
Dallas
2002 County
Program Expenditures Enrollment Source
Medicaid $1,202,119,500 190,000 Health and Human Services Commission
SCHIP $54,962,100 47,800 Health and Human Services Commission
Medicare DSH $34,454,800 NA Centers for Medicare and Medicaid Svcs.
Tax Support $310,763,000 NA 2002 Dallas County Budget
Other Public $20,153,800 NA
Tobacco Settlement $3,380,300 NA Texas Department of Health
Dallas City $5,241,800 NA 2002 Dallas City Budget
Dallas County Health $11,531,700 NA 2002 Dallas County Budget
Dept.
Parkland Foundation $8,163,600 NA Parkland Foundation
Private Hospital Charity $98,556,936 NA HMA estimate from self-reported data from
Care DMR member hospitals
Total $1,729,173,736 237,800
Medicaid/SCHIP
Medicaid accounted for the vast majority of available funding for low-income health care in
Dallas County at a little over $1.2 billion in 2002. This figure includes Medicaid
Disproportionate Share Hospitals (DSH) payments, additional reimbursement targeted to
providers who deliver services to heavy volumes of Medicaid and uninsured patients. Medicaid
is a joint state and federally funded program targeting low-income families, those receiving
cash benefits through other federal programs and low-income elderly and disabled individuals.
It is important to note that while Medicaid is an important financial partner for Parkland, rates
are significantly lower than other payment sources. The rates at Parkland drove a 2003
Medicaid shortfall of $72 million.
Texas State Children’s Health Insurance Program (SCHIP) funds accounted for about $55
million to providers in Dallas County in fiscal year 2002. SCHIP is another joint state and
federally funded health insurance program. This program provides health insurance coverage
for children up to age 19 ineligible for Medicaid with family income below 200 percent of the
Federal Poverty Level (FPL).

Medicare
Medicare is not a means-tested program, and reliable data on Medicare spending on low-
income beneficiaries is not readily available. Therefore, this analysis includes only those
Medicare resources expended in Dallas County through the Medicare Disproportionate Share
Hospital (DSH) program, which funds hospitals that serve a large proportion of Medicaid
patients and low-income Medicare patients. Dallas County hospitals received Medicare
Disproportionate Share (DSH) payments from the federal government in excess of $34 million
in fiscal year 2002.
Tax Support
The Dallas County Hospital District (Parkland Hospital and Health System) received $311
million in tax support in 2002 for indigent health care. This is based on the current rate of $0.254
per $100 of assessed value.
Other Public Support
The City of Dallas spent slightly more than $5 million on low-income health care services. The
majority of this spending came from the city’s general fund to finance neighborhood clinics
providing health screening and immunization services. The city also received about $725,000 in
grant funding from the Texas Department of Health (TDH) for disease screening, immunization
and lead abatement initiatives.
The Dallas County Health Department accounted for about $11.5 million of the total resources
dedicated to low-income health care in the county. The department expended about $7.2 million
of general fund dollars to health administration, public health and disease prevention efforts
and administered an additional $4.3 million in grant funding for disease prevention, training
and immunization efforts.
The Dallas County Hospital District received $3.4 million in 2002 from tobacco settlement
proceeds, pursuant to the settlement agreement dated July 18, 1998. Under the agreement, "all
hospital districts, other local political subdivisions owning and maintaining public hospitals,

and counties of the State of Texas responsible for providing indigent care to the general public”
are eligible to receive funds.
Parkland Foundation
The Parkland Foundation is a nonprofit corporation organized in Texas in 1985 to support and
benefit Parkland exclusively. Expenditures represented in the table are the support for low-
income patients channeled directly or through the Parkland Foundation to Parkland Health and
Hospital System in 2002.
Private Hospital Charity Care
In 2002, the major private hospitals in Dallas County provided approximately $99 million in
uncompensated care to self-pay and charity care patients, based on self-reported data.
E. Health Care Providers Serving Low-Income Patients in Dallas County
The Parkland System
The Parkland Health and Hospital System is by far the largest provider of low-income health
care in Dallas County, delivering services through its hospital, its COPC clinics, its specialty
care clinics and its Emergency Department and Level 1 Trauma service. The system provides
approximately half of the uncompensated care in the County. In fiscal year 2003, Parkland
provided $445 million in unfunded care (self-pay and charity care), representing 37 percent of
total hospital charges. Self-pay and charity care represented approximately 6 percent of total
charges among the other large hospitals in the County.
In the same year, Parkland provided $383 million in care (total charges) to Medicaid patients
and had a Medicaid shortfall (Medicaid costs minus Medicaid base payments and net UPL
payments) of approximately $72 million. This constitutes roughly one-third of the Medicaid
care provided in the County. Thirty-two percent of Parkland’s business was from Medicaid,
compared to approximately 16 percent for other large hospitals in the County (10 percent if
Children’s is excluded).

Private Hospitals
Private hospitals located in Dallas County constitute a significant resource in the provision of
health care services for the medically indigent, including both Medicaid/SCHIP and uninsured
patients. Children’s Medical Center, for example, delivers over 90,000 ED visits annually, with
72 percent of them either Medicaid/SCHIP or uninsured.
As determined by volume of Medicaid or uninsured services provided, the key private

hospitals in the County “safety net” include Baylor (University, Irving and Garland campuses),
Presbyterian and Methodist (Dallas Medical center and Charlton campuses). These institutions
all operate EDs that: 1) are very busy (between 41,000 and 61,000 visits annually); 2) have heavy
and increasing volumes of uninsured patients (between 25 percent and 37 percent); 3) have
heavy and increasing volumes of Medicaid patients (between 13 percent and 17 percent); and 4)
experience significant utilization for primary rather than emergent care, based on presenting
diagnoses and relatively low hospital admission rates. Further data on private hospitals are
included in the Appendices.
Private hospitals in the County also often provided significant amounts of care to low-income
patients, as summarized in Table 5 and Table 6 below.
Table 5
2003 Self-Pay/Charity Care Provided by Large Private Hospitals in Dallas County
(Inpatient and Outpatient)
Self-Pay/
Charity as
Self-Pay/Charity Care Total percent of
Total
Hospital Charges Cost Payments Charges
Children's $16,009,463 $7,593,146 $3,329,091 1.98%
Presbyterian $45,057,967 $16,883,220 $2,459,299 4.54%
Methodist Charlton $20,663,284 $9,228,223 $949,885 8.35%
Methodist Dallas $47,132,153 $22,543,309 $2,663,241 10.65%
Baylor University Medical Center $85,987,373 $31,359,595 $4,675,916 6.02%
Baylor Irving $25,495,045 $10,491,211 $1,391,191 6.78%
Baylor Garland $23,646,724 $9,184,388 $1,154,918 7.82%
Medical City* $45,596,411 $11,399,103 3.62%
St. Paul $21,469,507 $9,130,981 $1,549,539 5.44%
Zale Lipshy $2,859,575 $1,305,110 $989,167 1.35%
Total $288,321,091 $117,719,183 $19,162,247 5.54%
Source: self-reported data
*Note: Medical City is excluded from totals due to insufficient information

Table 6
2003 Medicaid Provided by Large Private Hospitals in Dallas County
(Inpatient and Outpatient)
Medicaid as
Hospital Medicaid Total % of Total
Charges Cost Payments Charges
Children's $433,306,059 $205,517,064 $166,715,101 53.52%
Presbyterian $83,069,692 $33,143,678 $28,669,836 8.37%
Methodist Charlton $27,534,810 $12,297,046 $10,554,513 11.13%
Methodist Dallas $67,506,431 $32,288,326 $28,858,351 15.25%
Baylor University Medical Center $139,479,297 $50,868,100 $53,036,655 9.76%
Baylor Irving $28,848,810 $11,871,285 $11,389,820 7.67%
Baylor Garland $22,684,158 $8,810,527 $9,155,392 7.50%
Medical City* $87,586,611 $21,896,653 6.96%
St. Paul $46,798,003 $19,903,191 $16,163,144 11.86%
Zale Lipshy $4,504,683 $2,055,937 $1,452,284 2.13%
Total $853,731,943 $376,755,154 $325,995,096 16.40%
Source: self-reported data
*Note: Medical City is excluded from totals due to insufficient information
Other Providers
In addition to the major hospitals of Dallas County, the low-income population accesses care
through: two Federally Qualified Health Centers (FQHCs), Martin Luther King Family Center
and Los Barrios Unidos; local clinics often established by faith-based groups; and via Project
Access, a program managed by the Dallas County Medical Society operated through a network
of volunteer physicians and hospitals. While these providers serve a small number of patients
relative to the Parkland system and other major medical centers, they are a critical piece of the
Dallas County safety net, especially for hard-to-reach populations (e.g., the homeless,
undocumented, and those lacking access to transportation). See Appendices for more
information on Dallas County Project Access, FQHCs and free clinics.
The public health departments of both the City of Dallas and Dallas County are significant
providers of health care services, concentrating on maternal and child health, immunizations
and communicable diseases (tuberculosis, sexually transmitted diseases and HIV/AIDS). In
addition, many physicians provide free care to patients in their offices, but there is no way to
quantify how much care they are providing.

Finally, the Veterans’ Administration operates a hospital and a network of primary and
specialty care clinics in Dallas and surrounding counties, delivering nearly one million
outpatient visits to predominately low-income people in the broader community.
F. Financing Low-income Health Care in Dallas County
Medicaid/SCHIP
Relative to non-Texas peer institutions, Parkland’s Medicaid reimbursement, including base

Medicaid payments and net Upper Payment Limit (UPL) and DSH payments, is very low. See
Appendices for data comparing Parkland to similar hospitals.
Poor payment rates are compounded by the State’s failure to capture appropriate levels of
Federal matching funds. In 2003, Parkland received gross DSH payments of $137 million and
gross UPL payments of $105. Parkland transferred a total of approximately $165 million to the
state as part of these transactions and netted approximately $77 million in DSH and UPL
payments. If all of the $68 million in overmatch was used to reimburse other hospitals, the net
benefit to those hospitals was approximately $170 million. Under the current reimbursement
system, Parkland still has approximately $150 million in unmatched local tax dollars.
Other counties have been much more successful in leveraging local tax dollars to support their
public hospitals. For example, in 2002 Cook County (Chicago) received approximately $240
million in Federal matching funds, net of amounts kept by the State, on local tax contributions
of $273 million. Wishard (Indianapolis) received approximately $80 million on total tax revenue
of $95 million, which includes amounts transferred to the local public health department. It is
important to note that both Cook County and Wishard use a variety of matching opportunities
to capture the appropriate amount of Federal match.
County Subsidies
Relative to peer hospitals, Parkland is heavily supported by local tax dollars. The following
table summarizes the tax support of Parkland and several other large public hospitals. As noted
above, almost half of Parkland’s tax dollars are unmatched.

Table 7
State/Local Subsidies to Selected Public Hospitals (2002)
Subsidy Subsidy
2002 State/Local per Person per Person
2002 County Subsidies to Subsidy < 100% < 200%
Hospital Population Hospital per Capita FPL FPL
Cook County 5,264,413 $273,090,254 $52 $372 $170
Denver Health 547,174 $26,900,004 $49 $299 $134
Harris County 3,505,268 $320,417,000 $91 $626 $260
Jackson Memorial 2,280,605 $250,028,809 $110 $600 $259
JPS Health Network 1,496,373 $171,573,000 $115 $990 $428
LA County – USC 9,578,096 $239,082,858 $25 $156 $66
Parkland 2,243,385 $310,763,284 $139 $910 $381
Wishard 842,236 $52,309,399 $62 $548 $216
Total/Average 25,757,550 $1,644,164,608 $64 $422 $193
Source: National Association of Public Hospitals (2002 Annual Member Survey) and US Census Bureau (2002
American Community Survey)

CHAPTER 2: HOW EFFECTIVE IS THE PUBLIC HEALTH AND HOSPITAL

SYSTEM IN DALLAS?
To best understand both the current and future priorities of the Dallas County Hospital District,
it is important to fully comprehend the complexity of the health care delivery system that it is
charged with administering. This Chapter will address:
• the effective integration of the Parkland component parts into an seamless continuum of
care;
• specific priorities for each level of care (primary, specialty, emergency, inpatient
services);
• gaps in the current system which may impact its optimum efficiency;
• the need for clinical disease management to cost-effectively care for the patient
population most likely to seek services through the Parkland system;
• the relationship of the Parkland system to its medical staff, primarily to the University of
Texas Southwestern School of Medicine;
• current and future financial management and strategy priorities for the system;
• physical facilities challenges, including the building priority issues for the system;
• potential partnerships with other Dallas health care providers; and
• the governance issues that shape the Parkland Health and Hospital System.
A. The Dallas County Hospital District as a System of Care
System-Wide Priorities
The Parkland Health and Hospital System is widely viewed to be one of the nation’s most
respected deliverers of health care for low-income populations and communities. Over a decade
ago, Parkland was one of the first public hospitals to understand that a hospital alone cannot

meet the needs of a medically vulnerable population and it moved care out into the
neighborhoods where its patients live by opening the Community Oriented Primary Care
(COPC) clinics. Through its partnership with the University of Texas Southwestern University
School of Medicine (UTSW), Parkland has excellent medical care providers and is a unique
training ground, producing many of the physicians now practicing throughout Dallas. It has
effectively struggled to remain cost-effective in light of a state Medicaid system that is one of
the lowest payers in the country and in the face of the pressures caused by growing numbers of
uninsured patients.
The challenges in the health care industry today, though, demand more aggressive creativity
than ever before, particularly for public hospitals. Parkland has all of the building blocks of an
effective system of care and needs now to focus on the operational issues necessary to make
“the trains run on time” as well as to continue to provide comprehensive health care services for
a growing medically underserved population. Significant progress has been made in reining in
costs, securing revenue, assuring quality of care and functioning efficiently in the midst of
enormous demands. There are several broader system issues that need to be addressed,
however, to continue to operate as an effective health care delivery system.
The discussion on the pages that follow will address specific aspects of the Parkland health
system. However, there are over-arching management and, even, philosophical issues inherent
in the operation of the Parkland system that will impact the resolution of any of these more
targeted concerns. These issues must be addressed in order to be successful in navigating
through the obstacles that Parkland will face in the years ahead.
In order to be most effective, both clinically and financially, the Parkland system needs to
function as a seamless continuum of care, avoiding the “silos” of management that may be
administrated independently and are not connected to the larger mission and operational
priorities. The services provided within the Parkland system need to be built around the needs
of the target patient population, the operations need to be designed to best assure the efficiency
of care provided to that population, and planning efforts need to integrate the financial,
administrative and clinical aspects of the service delivery system. There are very competent
clinical and administrative senior leaders throughout the Parkland system, but there appears to
be less cohesiveness than is necessary for optimal efficiency. It is important for all of these

leaders, including medical staff leadership, to have a clear understanding of the role of the
COPC clinics, the accessibility of specialty care, the financial state of the system, utilization
trends, and other issues impacting the entire system. It must be clear, for example, that
decisions made about the Emergency Department (ED) admission procedures or guidelines to
access certain specialty clinics or financial screening at COPC clinics or new research initiatives
undertaken at Parkland can have profound effects on areas of the system that may not have
been anticipated. The entire system must be viewed in the context of the whole, not as isolated
individual parts. A key element to assuring this coordinated and collaborative management
focus is the selection and appointment of a Chief Operating Officer for the Parkland system, an
effort currently in process.
The foundation of the clinical care delivered at Parkland is built on the “teaching model”
wherein the training needs of residents essentially guide policy and practice related to such
operational issues as admission policies, transfer decisions, specialty care allocation, and other
initiatives that should be determined by the leadership of the Parkland system, based on the
requirements for an effective clinical delivery system. Residency Review Committees (RRCs)
have already mandated that residents must function more like physicians-in-training and
significant strides have been made by UTSW and Parkland administration to assure greater
faculty supervision. The next step is to move away from the dominance of the teaching model
shaping clinical care by looking intensively and critically at policies and procedures and lines of
communication that have evolved over time that were developed to facilitate teaching rather
than efficient patient care. Across the country, other hospitals are working with their medical
school partners to take back some of the authority over the management of medical services
which had been for decades ceded to teaching programs. This is an enormous undertaking and
permeates most aspects of care delivered within the Parkland system, but the transition needs
to be tackled more aggressively in the years to come. It is also an effort that needs to be driven
collaboratively by both Parkland and UTSW, as neither is solely responsible for the current
situation and neither can change it alone.
While HMA does not believe, based on the evidence from public hospitals across the country,
that the Parkland system will ever resolve its financial stresses by significantly increasing the
proportion of privately insured patients that come to its clinics or hospital for their care, a

priority should be established and embraced to do everything possible to retain the paying
patients that currently use the Parkland system. There are specific operational policies and
procedures documented on the pages that follow that point to deterrents to retaining insured
patients, primarily Medicare patients, who initially come to Parkland for health services. There
are also particular service lines that attract significant numbers of paying patients that Parkland
must now refer to other hospitals because of their lack of capacity. Retention of current paying
patients to lessen the burden on taxpayers subsidizing the care of the uninsured should be a
goal of the system as a whole and should be coordinated centrally.
Finally, it is clear that Parkland Health and Hospital System cannot meet all of the needs of the
medically underserved of Dallas County alone. There needs to be constant evaluation of the
potential for creating new relationships and alliances that can result in a “virtual safety net”
for low-income people in Dallas County. While Parkland and the Dallas County Hospital
District must be vigilant to assure that they are not being inefficient within their own system,
they also must acknowledge that they need to develop partnerships with other providers to
assure that the respected model that they have built is sustainable in the longer term. All health
care providers, as well as the broader civic community, will continue to feel the pressure of the
growing number of uninsured. The key will be for Parkland to play a leadership role in
building rational connections that minimize duplication, equitably distribute responsibility and
most effectively meet the health care needs of the residents of Dallas County.
Primary Care
Most people in the United States receive the great majority of their health care in ambulatory or
outpatient settings. However, the growth of ambulatory care is a relatively recent phenomenon.
Less than a century ago hospitals were little more than almshouses and persons of even modest
means received most of their formal health care in their homes by the visiting solo practitioner
physician. Today outpatient visits include preventive care, involve addressing acute problems,
chronic disease management, and increasingly, procedures previously performed only in
hospitals.
Public health systems have been slower than private health care in providing significant
ambulatory care as they have remained in the role of provider of last resort, dominated by

inpatient facilities and emergency departments that attempt to catch the seriously ill who have
fallen through the cracks of the private health care system. More recently, public systems have
realized that ambulatory care is more humane and more effective in improving a population’s
health, plus a more cost effective approach. Today, public systems include all of the elements
and levels of ambulatory care from primary care through highly technical consultations and
procedures, including surgery. Increasingly, these elements are organized into coordinated
systems of care to increase their effectiveness and to use public funds more wisely. These
ambulatory care systems are integrated with and complementary to their public health system’s
acute care, inpatient and long term care programs.
Parkland Health and Hospital System contains the full range of ambulatory care facilities,
programs and practitioners required for a first rate ambulatory care system. Some of these
programs are creative and nationally recognized. Other ambulatory programs at Parkland
appear incorrectly sized to serve the population served by the system and are organized in
outmoded models. The following reviews the elements of Parkland’s ambulatory care, its
organization, functioning and integration in the Parkland system as well as the local healthcare
community.
It should be noted that HMA has completed a very thorough evaluation of the Parkland clinic system and
most of the specific detail of this analysis is contained in the Appendices to this report. What follows are
the key findings of this assessment.
The COPC Model. Parkland was one of the first public hospitals in the country to establish a
Community Oriented Primary Care (COPC) system of clinics in communities with high levels
of unmet health need that had previously been addressed almost exclusively by the often
inappropriate use of hospital Emergency Departments (EDs). Parkland understood that an
integrated system of care must shift the emphasis in health care delivery toward primary and
preventive care in order to provide the most cost-efficient and clinically effective model of care
for its patients.
Currently the COPC system consists of seven community-based clinics, the Ambulatory Care
Center (ACC) providing urgent care on-site at Parkland, employee health, campus-based clinics
for geriatrics and pediatric primary care, ten Youth and Family school-based clinics, and a

homeless program (HOMES). Collectively, these facilities deliver 327,485 adult, geriatric,
pediatric and behavioral health visits annually to approximately 121,872 patients. In addition to
the COPC network, the Parkland system, in partnership with the University of Texas
Southwestern School of Medicine, operates eight sites offering prenatal and other women’s
health services through the WISH clinics, five of which are co-located with COPC clinics and
three of which are independently housed. In 2003, these eight WISH sites provided 98,129
prenatal and women's health visits. Finally, two residency training primary care clinics (internal
medicine and family practice) operate at Parkland hospital and provide another 22,297 and
10,971 visits respectively.
While there are some differences between sites, these facilities generally function similarly and
offer medical services, health education, social services, pharmacy, lab and x-ray services. For
the most part, the COPC and WISH clinics are located in communities in which there are heavy
concentrations of low-income people and from which there is a heavy utilization of the
Parkland ED for primary care services that could be directed elsewhere.
COPC Patients. Although there is no reliable income data on COPC patients, approximately 40
percent of those seen in the COPC clinics are uninsured and 39 percent qualify for Medicaid or
the State’s SCHIP program, with the remainder of COPC patients covered by Medicare or other
funding. The COPC patients are heavily Hispanic and African-American (46% and 36%,
respectively). About half of the patients are children under the age of 14, 43 percent are between
15 and 64 years old, and 6 percent are over 65. Despite the different communities and
populations that the COPC clinics serve, all sites report the top two diagnoses for their patients
as hypertension and Type II diabetes, with asthma also in the top ten. These are all chronic
illnesses requiring ongoing management to avoid preventable and expensive ED visits and
hospitalizations.
The patients who come to the ACC on-site at Parkland are predominately adult walk-in patients
who suffer from long-standing chronic illnesses and are approximately 80 percent uninsured.
These patients are often referred to the ACC when they are discharged from the hospital and
need to be seen quickly or are triaged from the Parkland ED because they need primary, not
emergent, care. There is then an attempt to refer these patients to a COPC clinic to be seen on an
ongoing basis. The patients seen at the school-based clinics are predominately students of those

schools but three sites also are open to adults from the surrounding communities. The HOMES
program served about 5,000 homeless people during 2003 through a mobile program at 37 clinic
sites.
The patients seen at the WISH clinics are predominately Hispanic (80%) and uninsured (82%).
However, it should be noted that once these prenatal patients deliver their babies at Parkland,
their payor status changes and nearly 90 percent become eligible for Medicaid coverage. Thus,
the investment in prenatal care results in paying patients for the hospital.
COPC Productivity and Capacity. The federal government sets minimum productivity
standards for the providers who practice in Federally Qualified Health Centers (FQHCs) and
this standard serves as a rational benchmark for similar health care facilities. The COPC clinics,
as a system, fell short of those minimum standards for physicians in 2003, although they met
the standard for mid-level providers (nurse practitioners, for example). This doctor productivity
level caused concern among the Parkland COPC administration and an effort has been
underway, through an intensive team model, to improve this indicator. By the period of March
through August of 2004, the annualized number of visits per physician had increased from the
2003 rate of 2,794 visits/doctor to 3,484, still under the minimum federal level of 4,200 but
clearly significant progress has been made.
Reaching greater productivity by COPC providers is critical to effectively meeting the

increasing demand for services, particularly for chronically ill adults. If patients cannot get
appointments in the COPC clinics, they will likely seek care in the ED. As the average cost per
COPC visit is $90 and the average ED visit is $163, according to Parkland’s FY2003 Service Line
Analysis figures, it is clearly valuable to the system to keep as many patients in the clinics as
possible. In FY2003, the COPC clinics had the staff and physical space to provide 116,340 adult
and geriatric visits yet they actually provided 92,413 visits in that category. The productivity
efforts to date in 2004 have the clinics on target to come close to their filling their available
capacity.
In pediatric and adolescent services, there is also additional capacity in the current system.
Across the seven COPC community clinics, the school-based centers and the pediatric clinic on
campus, there is additional capacity, at current staffing levels, for approximately 2,300 visits per

month, according to productivity benchmarks. There has been an improvement since 2003
when there was capacity to provide an additional 35,000 visits. As children are most likely to be
covered by Medicaid or SCHIP, it should be—and is—a system priority to increase pediatric
visits. It appears that most of the 16,000 babies do receive and keep their follow-up
appointments at COPCs but it is unclear whether these children stay in the system after initial
newborn visits. Further, the Parkland Community Health Plan, the system’s Medicaid/SCHIP
managed care entity, assigns less that half of its children to COPC providers. This would be an
additional opportunity to increase pediatric utilization. Finally, the utilization of the ED at
Children’s Medical Center, which has increased precipitously over the past year, comes from
communities in which COPC clinics are located. A formal arrangement to refer patients from
the Children’s ED directly into COPC clinics would benefit both institutions and the patients as
well.
A common complaint from COPC Advisory Board members, the Parkland ED and staff in other
community hospitals is that it is extremely difficult to get an appointment in the COPC clinics.
There is clearly an ability to accommodate additional patients and the productivity efforts
currently underway are increasing that capacity still further. The focus should now expand to
administrative and policy barriers that may be impeding access.
COPC Physicians. The physicians who work at the COPC clinics are employees of Parkland
and are not included on the UTSW faculty contract, even though many of these physicians were
trained at the University and hold clinical appointments there. When the COPC clinics opened,
the University was not interested in providing physicians so Parkland recruited their own.
There are several areas where these two different physician classifications, based solely on
employment status, cause problems for continuity of care, for patient satisfaction and,
ultimately for cost-effectiveness.
When a patient needs to be referred from a COPC clinic to a specialty clinic at Parkland, the
COPC doctor has to talk to a resident at Parkland. Most COPC physicians stress the frustration
of trying to convince a physician-in-training that they, as seasoned physicians, are capable of
determining whether their patient needs a referral and they often end up sending their patients
to the ED to try to get into the care they need. Further, although there is a policy allowing for
COPC doctors to directly admit their patients to Parkland Hospital, it does not function well.

Usually patients are sent to the Parkland ED and they wait in line for admission with everyone
else. Clearly, these scenarios represent problems for continuity of care but it is also the case that
if there is an option for the patient to go to another hospital (i.e., if they have insurance) they
will rather than have to endure the waits for admission or consults or diagnostic tests at
Parkland. (Interestingly, this connection between COPC doctors and hospital-based doctors
works much better for the pediatricians who want to send patients to the Children’s Medical
Center as many of the COPC pediatricians are on Children’s medical staff, make rounds there
and supervise Children’s residents in the COPC clinics).
The need for strong physician leadership within individual clinics and as a system, is a clear
priority for the COPC network. While there are Lead Physicians throughout the network, and
the COPC Medical Director is charged with coordinating key quality improvement strategies,
there is not a vehicle for coordinating patient care with physician counterparts at the specialty
and inpatient tiers of the system. Addressing this physician-to-physician communication issue
needs to take place at the level of senior leadership of the Parkland system. Further, in order to
move the clinics to an aggressive management of chronic diseases, essential for the effective and
cost-efficient management for a disproportionately large portion of the COPC patient
population, there will need to be strong physician leadership empowered to guide the effort.
(The issue of instituting a chronic disease management program is discussed at greater length
later in this report).
Operational and Policy Issues. The COPC clinic network is administered by a Parkland Vice-
President who is supported by a team of twelve directors and associate directors. Each
individual site is led by a Site Administrator and has a Lead Physician in each specialty and a
Lead Nurse. Most clinics have Advisory Boards that provide input into the development of
programs and bring the staff a perspective on patient satisfaction and community concerns.
A major focus of COPC administration over the past several years, in addition to provider
productivity, has been to improve the screening of its patients for all insurance coverage
programs for which they may be eligible and to enforce the collections of cash co-payments,
which are collected on a sliding fee scale according to income eligibility. Further, uninsured
patients are required to enroll in Parkland Health Plus, the managed care plan for the
uninsured, or they will be required to pay a greater co-payment. These efforts have

demonstrably had an impact on revenue generation but there has been little assessment of the
perhaps unintended consequence of patients seeking their primary care in the ED, where they
cannot be turned away, rather than comply with the financial screening requirements at the
COPCs.
A policy has been enacted at COPC clinics that results in the refusal of care, except at full cost,
to any person who works for a business that offers health insurance to its employees, regardless
of the cost to the employee of securing that coverage. This policy should be re-examined. Most
of the uninsured in Dallas, as in the rest of the nation, work full-time. Many businesses have
either limited their insurance coverage to catastrophic medical expenditures or have made the
premiums borne by the employee high enough that many opt out. The COPC policy, however
well intentioned to minimize abuse of the system, may be sending more people to the ACC or
EDs (either Parkland’s or others), resulting in a greater cost to the system.
Access to COPC services is an issue with several components. First, most of the clinics are only
open during weekdays, with no weekend or evening hours (although two sites do open for
urgent care on one weekend day each). As a system, and building on efforts to increase
productivity, it would make sense to explore the reallocation of staff from less busy clinics to
those with greater demand, expanding hours in the process. This effort is already underway. In
addition, there seems to be a variety of opinions on the effectiveness of the COPC appointment
system. There is a widely held perception that it is very difficult to get an appointment to a
COPC clinic in a timely manner, although most sites have available capacity. In an effort to
understand the reality of this situation, HMA attempted to make appointments and did, indeed,
have significant difficulty in gaining appointments. Addressing the appointment scheduling
process should be seen as a priority for COPC administration. There are efforts underway to
move toward a centralized appointment scheduling system.
Finally, the COPCs need to be operationally integrated more effectively into the Parkland
Hospital system. In addition to direct admission and specialty care referrals, discussed above,
there is no organized and monitored process for patients in the Parkland ED to gain
appointments for follow-up care in a COPC clinic near to their home, breaking the pattern of
unnecessary ED utilization for primary care. The impact of COPC policies on other aspects of

the Parkland system (i.e., financial policies that may send more patients to the ED) need to be
understood and monitored and vice versa.
Size and Location. As the pockets of medical indigency and poverty change in Dallas County,
there may be less need for one COPC clinic and greater need for another, or there may be
growing demand in a neighborhood where there had been no COPC clinic before. The
monitoring of need should go hand-in-hand with productivity enhancement efforts. New clinics
do not need to be built or existing ones expanded if they are not operating at full capacity.
However, when existing facilities are at full capacity and there is still demand, additional
COPCs will likely be needed. The growth in the number of uninsured in the County will mean
that people will either utilize COPCs or EDs for their care. Clearly, it is financially more rational
for Parkland to direct patients into clinic settings. Further, as community private hospitals are
experiencing significant increases in the use of their EDs as a source of primary care for the
uninsured, there are real opportunities to develop partnerships with these providers for either
expansion of existing clinics or development of new ones.
The proposal to develop a new COPC in Irving is a good example of a responsible way to
approach COPC growth. Irving, as a community, is increasingly Hispanic and uninsured.
Residents of that community already account for nearly 10,000 Parkland ED visits, 14,000 visits
to other COPC clinics and 55,000 other outpatient service encounters. A plan was developed for
Parkland to secure support from Baylor and government grants to help fund a new site of clear
need. This model could well be pursued in other communities with documentable need.
Parkland owns and is maintaining two empty clinic buildings previously owned by Kaiser, one
in Oak Cliff and the other in Southeast Dallas. The evaluation of the potential use of these two
clinics should commence. In particular, the current Oak West COPC clinic is small, cramped
and operates at capacity. The potential relocation of that clinic into the Oak Cliff Kaiser facility
(along with the WISH clinic) should be explored as a vehicle for increasing access in an area
where there is high demand. The potential for a partnership in Southeast Dallas should also be
evaluated, perhaps as a site for increasing specialty services.
Finances. Few, if any, primary care networks—public or private—make money in and of

themselves. Primary care systems focused on providing care for the medically indigent will

clearly never break even, based on Medicaid reimbursement rates for outpatient services and
the inability of many uninsured patients to cover the full cost of care. As the payor mix for
COPC patients is essentially 90 percent dependent on federal, state or local government sources,
the system will always need to be subsidized. However, it is also important to fully understand
the true level of subsidy (as opposed to hospital overhead) and the impact for the rest of the
system (i.e., allocation of costs, deflection of patients who otherwise would have utilized the ED
for care).
The best opportunity for the losses of the COPC system to be minimized is the conversion of the
clinics to Federally Qualified Health Center (FQHC) status, a designation by the federal
government that guarantees cost-based Medicaid and Medicare reimbursement. As the COPCs
currently meet all of the requirements for populations served and scope of services provided,
and because the governance requirements for public sector FQHCs are considerably less
constrictive that those in the private sector, and because the revenue increase would be so
substantial, HMA believes that this should be a major focus for the Parkland system. The
financial implications are discussed fully in the Finance section of this Chapter.
Conclusion. The Parkland COPC network should be viewed by the residents of Dallas County
as a vital resource in their health care safety net and the continuing commitment to meeting the
primary care needs of medically underserved populations and communities should be a
priority for the Dallas County Hospital District. Attention to operational and policy issues
which impact productivity and access, better integration into the entire Parkland continuum of
care (specialties, ED, inpatient), fully developing a chronic disease management model for
COPC patients, constantly monitoring the appropriateness of staffing and location, continuing
to push for financial viability and new focus on building partnerships with other providers
should all be priorities for Parkland and COPC leadership.
Specialty Care
The Importance of Outpatient Specialty Services. Specialty outpatient medical services are
essential to the Parkland system as well as to other providers caring for low-income residents of
Dallas County. These specialty services are critical in addressing health disparities for poor and
minority patients and in assuring the appropriate treatment of disease. There is growing

pressure on Parkland, as there is on public hospitals in large urban areas across the country, to
address the issue of access to specialty care. The growing population of the Parkland system is
heavily made up of chronically ill adults who require access to specialty care to most effectively
manage their illnesses. In addition, the broader safety net of private physicians, community
hospitals, federally-supported health centers and public health departments have no other
option for specialty care for their uninsured patients and either refer directly to Parkland’s
specialty clinics or, more often, refer indirectly through the hospital ED. Finally, the demand on
Parkland for specialty access is growing as other traditional providers of those services, private
physicians or academic medical centers, are limiting access to Medicaid covered patients
because of decreased reimbursement, or are leaving poor communities altogether.
At first, the notion of allowing access to Parkland’s specialty services might elicit fears of
uncontrolled spending and excessive use of expensive, marginally-beneficial technologies. It is
responsible to attempt to avoid the runaway growth of technology and the specialty focus that
characterizes the U.S. health care system and is a major cause of the cost crisis in health care that
the nation faces today. However, there is a clear role for appropriate and cost-effective specialty
care in public systems such as Parkland’s. Emerging research demonstrates that diminished
access to some specialty services—for example, revascularization procedures—actually
magnifies costs by greatly increasing hospitalization rates. In addition, limiting access to
clinically effective and cost efficient specialty care has been identified as one of the reasons for
the health disparities suffered by poor and minority populations.
Outpatient specialty care is an essential adjunct to primary care prevention strategies. For
example, screening breast exams and mammography are worthless without follow-up,
ultrasound-guided biopsies. Colon cancer screening with fecal occult blood testing mandates
access to colonoscopy, which allows removal of pre-cancerous polyps and early cancers and
thereby reduces mortality and medical expenses. Another example involves special eye exams
and laser treatments for patients with diabetic complications—proven to prevent blindness and
save money. In addition, without efficient outpatient specialty care it is impossible to maintain
sizable and efficient elective inpatient medical care. Many public hospitals maintain that they
are too busy taking care of acute problems to focus on efficient elective care. However, what
they are really abdicating is caring for elective health matter in anything other than an urgent,

and often chaotic, manner. Elective patients, particularly those with insurance, that have been
previously cared for at Parkland, are discouraged and driven away, leaving only those
uninsured patients who have nowhere else to go.
Access in the Current Parkland System. A clear problem exists in access to specialties at
Parkland. The COPC clinic physicians report that they are often unable to successfully refer
their patients to many of Parkland’s specialty clinics. New patient appointments, if obtained,
are far in the future. If a patient does attend a specialty clinic, a report from the specialist
consultant rarely returns to the referring primary care physician. As a result, a number of COPC
patients who are insured find their way into the private system for outpatient specialty
consultation and are more likely to be admitted into private hospitals for elective procedures
and surgery. The Emergency Department also faces a similar situation. The conventional system
of referral is not reliable and if physicians are concerned about a particular patient they directly
call a physician working in the outpatient specialty clinic and obtain an appointment by going
around the formal system. Community physicians who care for any indigent patients in their
practices state that it is virtually impossible to refer to Parkland for specialty care. Community
groups and Parkland community advisory groups complain vociferously about access to
specialty services.
It would be rational to conclude that a problem with access is a problem with capacity.
However, with a dysfunctional referral system, the highest priority patients may not
successfully be referred and no-shows and other inefficiencies are endemic. Further, the
assignment of specialist clinical time within the system to meet the demands of the population
is where much of the problem may exist. Cardiology is illustrative of this point. Heart disease is
the major cause of death in Dallas and one of the major causes for admission to Parkland
Hospital. Parkland contracts with UTSW for 11.5 FTE cardiologists. However, the Cardiology
clinic, the portal of entry to elective cardiology care, sees what appears to be a number of
patients that could be seen by 1.5 FTE attending cardiologists. The clinic meets only two half
days a week and appoints patients only to Cardiology Fellows in training. After seeing the
patient, the Cardiology Fellow does not usually provide directions to the primary care
providers to follow recommendations that have been sent to them. This increases the amount of

follow-up care Cardiology clinic must perform and decreases the number of new patients that
can be seen.
The Organizational Model. Price Waterhouse Cooper reviewed outpatient services at Parkland
Hospital and stated that the Outpatient Specialty Center operations were designed to meet the
training needs of the University of Texas Southwestern School of Medicine. Observation of the
specialty clinics reveal that teaching needs and academic interests drive the services, staffing,
hours and operations of the specialty clinics. To a varying degree in different clinics, patients
may be seen by trainees and students who present the case to a faculty physician who
personally never lays eyes or hands on the patient. All specialty services are centralized in one
facility although Parkland’s outpatient specialty referral manual lists 162 separate clinics. Many
of these separately designated clinics reflect current or past research or training interests rather
than the contemporary organization of ambulatory care.
The training model in Parkland is dated and does not absolutely need to persist. There are clear
degrees of difference between clinics. The Gynecology Dysplasia clinic, for example, operates
on a model that is driven by the perspective of providing sufficient levels of care to meet the
needs of the population. Faculty gynecologists are directly involved with care and seem to
believe it enhances the learning process for trainees. They have policies and procedures to
assure that patients do not fall through the cracks in the system. This clinic may not be perfect
but it’s a model that is built on a public health perspective, is more efficient, and is related to a
primary care system of care. Other clinics also have developed around solid participation of
faculty physicians in the care of patients. It provides encouragement that the teaching model
can be restructured in the Parkland system.
Redesign of Outpatient Specialty Care. Parkland should take measures to systematically

determine the total predictable demand for each specialty from its ED, COPCs, inpatient follow-
up and traditional referrers into the Parkland system. At the same time, unmet need within the
Dallas community, particularly for populations that traditionally utilize Parkland, should be
assessed as many people have simply quit trying to get into care and are just showing up at the
ED when such visits could have been prevented. Present outpatient capacity at Parkland should
be compared to this assessment of need and the gap quantified. The current assignment of
specialist effort, purchased through the UTSW faculty contract, should then be evaluated and

redirected to ambulatory care, if feasible. Parkland leadership should review the utilization of
exam rooms dedicated to specialty care to assure that time is allocated effectively (which
doesn’t appear to be the case currently). A collaborative effort should be undertaken between
Parkland administration and UTSW medical staff leaders to make sure that clinic hours and
space are allocated based on the clinical needs of the Parkland patient population, not solely
assigned based on teaching priorities. After all of this analysis is completed, it may be necessary
to invest in more specialists in order to meet the needs of the Parkland population, but that
decision should not be made until a thorough review of the efficiency of the current system is
completed.
Further, a practical and accurate method of determining the appropriateness of specialty care
referrals needs to be constructed. This determination may be able to be integrated into a
mechanism that includes an electronic referral request and approval system that is able to track
individual and clinic referrals. For example, every patient with a headache does not need to be
referred to a neurologist but there needs to be a clear mechanism for assuring that the patients
in greatest need of specialty care do receive appointments. This referral system may be part of
Parkland’s current information system or could also be a stand-alone operation. An effort like
this is currently underway in the Cook County system in Chicago and has been successful in
reducing both backlogs and inappropriate utilization of specialist resources.
Most patients referred into specialty care should have primary care practitioners and specialists
should begin to act more like consultants, as they do in the private sector. Thus, specialists in
the Parkland system need to be available to answer the questions of the referring provider,
provide clear and concrete recommendations, and assure that the patient and the
recommendations get returned to their primary care provider. New ways to increase access to
specialty assistance within the constraints of the available resources should be explored by the
hospital as support to the physicians (e.g. e-mail consultations, training primary care providers
to deliver more specialty care, etc.).
A process of redesigning the organization of the specialty clinics at Parkland should begin.
Direct care and, if necessary, continuity with a faculty physician should be a core goal. Clinics
should meet several times a week rather than in a single enormous session. Real connections
with the rest of the Parkland system should be constructed. Teaching can and should be

continued in such redesigned specialty services clinics but it should be layered over an efficient
delivery system, not be the driving force. This is also a better training experience for future
physicians.
Finally, Parkland leadership should actively consider and pursue partnerships with other
hospitals and their medical staffs to increase access to specialty outpatient care in community-
based settings, off of the main campus. For example, Parkland should explore whether hospitals
and groups that are located near COPC centers might play a role in providing specialty care.
The number of indigent in Parkland’s patient population makes this a complicated proposal,
but in talking with these organizations and understanding the impact on private hospitals of
inappropriate utilization of their EDs, it was clear that there is a definite willingness to discuss
this option.
Conclusion. Parkland has very competent and dedicated physicians who provide excellent
quality of care to their patients. The reorganization and refocus of the specialty care outpatient
clinics, however, must be a significant priority for Parkland’s administration and for its
physicians in order to more effectively and efficiently meet the needs of its patients. Specialty
outpatient care is, in many ways, the linchpin in assuring that patients can avoid unnecessary
hospitalizations and ED visits, effectively manage their chronic diseases and even keep them in
the system when they have insurance and other options. This area of the health care continuum
should be viewed as a major priority for the health system.
Emergency Care
The Parkland Hospital Emergency Department (ED) serves as the front door to the community.
Typical of other public hospitals, most persons admitted to Parkland’s inpatient units enter
through the ED, almost twice as many as are admitted through EDs at other large private urban
teaching hospitals. The Parkland ED is crowded and waiting times are excessive, reflecting the
experience at other public hospital EDS around the country. This growing phenomenon is
ascribed to lack of access to primary care, enactment of EMTALA laws that mandate that the ED
must not turn anyone away, increasing numbers of uninsured, and a change in the health
seeking behavior of both the insured and uninsured. It has been said that the ED has become
the “safety” of the safety net.

There is one critical difference at Parkland. In the past several years, the number of persons seen
and treated at Parkland’s ED has actually diminished unlike the experience of other urban
hospitals. The decrease in numbers may be viewed as a success of Parkland’s ambulatory care
expansion, or as a diversion of some of the traditional demand Parkland has borne now being
shared by other Dallas hospitals. However, the patients who still use the Parkland ED and the
staff that work there are dissatisfied with the effectiveness of its operation. This dysfunction can
readily be witnessed in any visit to the ED waiting room and is reflected by such benchmarks as
the average time it takes to complete a patient visit.
The medical staff and nursing personnel are of high quality and committed to improving care in
their Department. How can it be, then, with decreased volume and strong and knowledgeable
staff that the current situation exists? The answer can be found in studies of emergencies
services nationwide. The backlog in emergency rooms does not correlate so much with how
many people arrive for care but, rather, with how readily and successfully the ED is able to
admit patients to beds in the hospital. At Parkland, the average emergency room visit takes 7
1/2 hours. A patient who is admitted to the hospital, however, spends an average of 13 hours
waiting in the ED for an inpatient bed. The result of these excessive delays is that almost 12
percent of patients leave the ED before they are treated by a doctor. When delays are excessive,
the ED diverts ambulances away.
ED Delays and the Inpatient Admissions Process. Patients waiting to be admitted to inpatient
units continue to occupy space and resources in the ED and prevent other patients from being
seen in a timely fashion. At all hospitals, and especially at Parkland, the ED is not really the
master of its own fate. Emergency Departments’ delay problems and bottlenecks usually reflect
malfunction downstream in admissions, bed control, and discharge practices, and not strictly
the number of patients that present at their doors. Approximately 80 percent of all inpatients at
Parkland have been admitted through the ED. Parkland has a glaring problem with inpatient
admissions from the ED that has been identified previously in at least two independent
consultant reports.
Although the ED is staffed with highly trained Board-certified Emergency Medicine attending
physicians, their decision to admit a patient with a medical condition--be it heart disease, a
serious infection, or cancer—does not mean that the patient is promptly sent to an inpatient

unit. Instead, the patient’s case is referred to a designated medical resident (the “A.O.D.”) who
then begins another evaluation, ostensibly to decide if the admission is altogether appropriate
and to determine to what kind of bed the patient should be assigned. On a recent visit to the
ED, the AOD was a second year resident less than a year and half out of medical school. He had
at that time eight patients awaiting this second evaluation. It was clear that he also was on the
phone with residents upstairs on the medical floors negotiating the terms of the admissions.
Further, medical residents insist on diagnostic tests being done while the patient is still in the
ED, a workup that is actually part of the inpatient care, because they say that it is easier to
obtain the tests in the ED. However, that operational detail is cause for hours of additional
delay in the admission process. In the meantime, the spot in the ED is unavailable for use to
assess other patients who are waiting. Once a patient is actually assigned to a bed, there are
additional delays due to issues of bed control that are covered in the Inpatient Care section of
this report
The COPC clinics have great difficulty in admitting patients to Parkland. They are forced to
send patients to the ED who could otherwise be directly admitted. The ED AOD again
reassesses the patient. Specialty clinics within Parkland also admit their patients through the
ED. It is stated that the AOD makes certain that the COPC and specialty patients do not
displace a higher priority patient already in the ED. However, almost all of these patients are
ultimately admitted but only after a prolonged and, from the perspective of the patient,
unnecessary delay in a noisy and crowded area. Directors of private hospital EDs within Dallas
County also experience the necessity to convince a relatively junior trainee of the
appropriateness of transfers to Parkland. Admissions are simply not allowed to internal
medicine wards between the hours of 4 a.m. and 7 a.m. Monday to Thursday, or between 2 a.m.
and 7 a.m. on Friday through Sunday. This is meant to accommodate the intern and resident
workloads. In the meantime, patients wait until morning. Since the early hours after 7a.m. are
particularly hectic, patients may not actually be accepted until 10 a.m.
There is clearly a need for some method of assessing and assigning admissions. However, the
system in place at Parkland reflects organization and control that serves the teaching programs
rather than a contemporary health care operation. The level of experience and the pressure felt

by a resident often cause them to be myopic and blind to the needs of either a hospital
organization or the population that the health system seeks to serve.
Connections with Primary and Specialty Care. When patients registered in or referred from
Parkland COPC clinics or patients from other Parkland ambulatory care sites have been treated
in the ED, there is no consistent and effective method of sending results back to their original
referring physician. Likewise, when patients have no primary care or need specialty
consultation and follow up, the system for referral to get patients into ongoing care is
unreliable. In fact. it is so unreliable that ED physicians worry that patients may fall through the
cracks and they often work around the formal referral system and attempt to call a resident or
fellow who is on the specialty rotation in order to gain an appointment. Even then, patients who
need urgent outpatient visits may be turned away by the mechanics of the financial interview
process and given an appointment to return to see a physician many months later.
An effective system of specialty and primary care referrals could clearly reduce return visits to
the ED, especially for patients with serious chronic illness. Accessible referrals are also likely to
avoid expensive future hospital admissions. Other policies, such as the prohibition of providing
inhaled steroids to asthmatics at the conclusion of acute exacerbations (because such a
treatment would constitute “preventive care” not provided in the ED) are irrational and short
sighted, as such a practice almost guarantees return visits in the near future.
What Should Be Done? A critical assessment should be made of how Parkland’s ED can be
reconfigured to meet the needs of the population it serves. Operational policies must be
changed that do not achieve this or actually serve as obstacles. Changes that can and should be
made include:
• Improve the ED waiting room space.
• Design a system and give authority to a single designated clinician that determines if a
patient is to be admitted and to where within Parkland Hospital (i.e., eliminate the AOD
system).
• Allow and facilitate direct admissions to inpatient beds with rare delays for patients
within the Parkland health system, including the COPCs.

• Stop requiring diagnostic tests, procedures, and workups in the ED as a requirement of

admission that are more appropriate for inpatient units. If, for the same patient, tests are
easy in the ED but difficult on the floor, reallocate and redesign policies and practices to
remedy this situation.
• Plan the construction of Observation Beds in or adjacent to the ED to avoid admissions

that are inappropriate and will be served better and more quickly by using an approach
that has succeeded in similar clinical facilities.
• Improve bed control to meet accepted benchmarks and thereby provide more capacity
and relieve waiting, backup, and diversion for the ED.
• Redesign the process to allow referrals from the ED into primary care and specialty
clinics, and referral back for follow up care to sites that provide ongoing care for
patients.
• Review and change clinical and administrative policies and practices that are likely to
encourage unnecessary return visits to the ED.
• Evaluate and implement interventions and policies that are consistent with using the ED
as an element in a disease management approach to the patients with chronic illness and
conditions cared for by Parkland. (see Disease Management section of this report).
Inpatient Care
HMA’s assessment of the inpatient services at Parkland Hospital was based on discussions with
Parkland’s medical and administrative staffs, independent observation on clinical physician
rounds, data analysis and review of previous consultant reports on targeted operational areas.
The following discussion is focused on the strategic areas that represent only the most
immediate priorities for the system.
Bed control. The ability of a hospital to discharge patients in a timely way, freeing up beds for
new patients waiting to be admitted, is a major factor in the efficient operation of any hospital.
For Parkland, the ramifications of an ineffective bed control system are profound. Not getting
patients out of beds who can leave the hospital means that there are fewer beds available to
move patients up onto inpatient units, causing massive backlogs in the ED. It means not

admitting some paying patients who have options to go to other hospitals when there are long
waits for admission to Parkland, depriving the hospital of the revenue that admission would
bring. It means keeping patients in the hospital unnecessarily and, for those patients with no
payer source, burdening the hospital with the cost of those unnecessary days. Finally, it means a
distorted reporting of patient census (i.e., the average med/surg census may be 72 percent at
midnight but 94 percent at 1:00 p.m.).
Currently at Parkland, very few patients who will be discharged during the day get their
discharge order written by the physician before noon, the industry benchmark. Further, there is
a very long wait from the time that the discharge order is written and the time that the
availability of the bed is entered into the hospital’s computer system (often 6-9 hours). Finally,
there is still further delay in getting the empty beds cleaned and ready for additional patients.
Over the past several years, there have been significant efforts by the administration of the
hospital to address this problem. Several consultants have developed implementation plans for
restructuring bed control at Parkland and attempts have been made to work with doctors to get
orders written earlier and to have unit managers more accountable for getting the information
about bed availability into the computer. Most Parkland administrators acknowledge, however,
that bed control remains a significant problem.
Rehabilitation Inpatient Capacity. Parkland Hospital currently operates 14 inpatient

rehabilitation beds. In 2002, the hospital’s internal demand for those beds exceeded its capacity
by 300 percent. Parkland admitted 279 patients into these beds and referred 485 patients to
other institutions, simply because they had no available beds. The patients that Parkland kept
were primarily uninsured (87%) and those that were transferred out were primarily insured
(96%). This is a significant opportunity lost to keep paying patients in the institution who
wanted to come there. With the aging of the population, this demand will only grow.
Ultimately, the issue of additional rehabilitation inpatient capacity needs to be addressed in the
planning for a replacement for Parkland Hospital. There are opportunities in the shorter term,
however, to look at less drastic ways to increase Parkland’s ability to maintain these paying
patients. There are two inpatient units (1S and 2S) that are currently not utilized for clinical
services that could be retrofitted for additional rehab beds. In addition, there has been some
interest expressed by UTSW to develop a partnership between Parkland and Zale-Lipshy to

jointly expand rehab services at both institutions, with each institution perhaps concentrating
on particular sub-specialty areas.
The exploration of both short- and long-term strategies to increase inpatient rehabilitation
capacity at Parkland should be a programmatic priority for the institution.
Operating Rooms. The operating room (OR) capacity at Parkland and the efficient use of that
capacity is having far-reaching impacts of the entire institution. Over the past two years, there
has been a significant increase in the average length of stay (ALOS) for surgical inpatients, with
a jump of nearly two full days to the current ALOS for 7.6 days. It is not uncommon for patients
to be admitted to the hospital for a surgical procedure, wait in a bed for several days because
their surgeries have gotten “bumped” by emergency trauma cases, sometimes leave the hospital
to come back another day. This is poor patient care, unnecessary utilization of inpatient beds
(for which services cannot be billed because no service was provided), and a guarantee that any
patients who have other options to get their care elsewhere (i.e., are insured) will do just that.
The lay-off of eleven surgical case managers as a result of the hospital’s “Transforming Care”
initiative is widely believed to have crippled the effective management of the ORs. Operative
cases are now scheduled almost entirely by residents. These doctors, who need to experience
certain kinds of surgeries as part of their training, will often look for the most “interesting”
cases, leaving general surgeries behind. It is very difficult, for example, to schedule a routine
gall bladder or hernia operation in the Parkland ORs.
The lack of OR capacity and effective management are also resulting in physicians scheduling
patients at other hospitals if they have insurance, simply because they don’t have access to the
OR time at Parkland.
In order to address the operational, clinical and financial problems resulting from the current
surgery situation at the hospital, several steps should be taken. First, the development of the
Ambulatory Surgery Center, already endorsed by the Dallas County Hospital District, should
proceed as rapidly as possible. Second, the hospital should explore the potential for leasing OR
space in other institutions as an interim plan for moving outpatient surgeries out of the
Parkland ORs. Apparently preliminary discussions are currently underway with St. Paul

Hospital. Finally, the OR management needs to be taken away from residents, even if that
means replacing the case managers who had previously administered the area.
Labor and Delivery. Parkland has, by far, the single largest obstetrical program of any hospital
in the United States. At around 16,000 births per year, it has about twice the number of the next
busiest hospital in the nation. It also produces irrefutably positive results and has impacted the
entire County’s infant mortality health status in a positive way.
On the inpatient labor and delivery units, the services are operated under a protocol developed
by the UTSW OB/Gyne Department. It is difficult to argue with the operation, given both the
enormous challenges of managing the volume of patients and of the ultimate clinical results.
Operationally, however, the inpatient practice model, utilizing four different inpatient units
within the hospital, results in some units with census of over 90 percent and some at 50-60
percent. Some units have women delivering in hallways where other units have unoccupied
beds.
The reorganization of the labor and delivery units to assure greater consistency in census is
important for both the institution (which needs to fully utilize all available beds) and for the
care of the patients. Given the anticipated increase in obstetrical services at Parkland, this effort
needs to take a priority within the institution. The UTSW Department has indicated a
willingness to work with Parkland administration to develop a better use of bed capacity and
the planning should be initiated as soon as possible.
Direct Admission from COPC Clinics. As has been described elsewhere in this report, there is
no effective way currently for physicians in the COPC clinics to directly admit their patients
into Parkland Hospital. They must send them to the ED where they wait in line through the
long triage process. The result is that most patients in the clinics who have any form of
insurance, and there is a substantial number of them, will go to other hospitals. If one of the
system-wide priorities is to keep those paying patients who already identify with Parkland in
the system throughout the course of their care, resolving this issue should be of paramount
importance. It will require, as will many of these operational restructuring recommendations,
directly addressing the teaching model at the hospital as admissions are organized around
resident services.

Conclusion. There are enormous challenges inherent in running a hospital of the size and
complexity of Parkland. There are also many highly qualified administrators who are
addressing these challenges every day. Many of the operational priorities identified above will
require a thorough restructuring of the current teaching model. Physician leadership and a
strong operational focus, perhaps strengthened with the recruitment of a hospital Chief
Operating Officer, will need to work in a collaborative way to take on these tasks.
Gaps in the Current System of Care
The Parkland system does not—nor should it—directly provide all of the health and social
services necessary to assure an effective use of medical resources. Without a formal way of
assuring access to those services that it does not provide itself, Parkland will often bear the
brunt of a gap in the continuum of care that will result in the inappropriate use of its own
services. For example, patients are often kept in acute care beds in Parkland Hospital because of
the difficulty in finding long term care (nursing home) beds for them in private institutions.
This is a particular problem for patients who may have ongoing medical, substance abuse,
mental health, social or a combination of these problems. Other patients may end up being
admitted to the hospital who could have otherwise be cared for in less costly venues if the
services that they required could be delivered in an outpatient setting. This is clearly the case
with surgeries that could be provided in an outpatient setting if it existed within the system.
Still others represent potential sources of new revenue for Parkland if the gaps in the system
could be closed, like rehabilitation services discussed above.
Parkland administration needs to review the potential for filling holes in its current system by:
1) assessing opportunities for mutually beneficial partnerships with other providers already
delivering those services; and 2) creating business plans for potential new services to both
generate new revenue and to allow it to utilize its current levels of care more effectively. In
addition to developing ambulatory surgery and additional rehabilitation services described
above, the key area of primary focus for Parkland should be the development of a formal
arrangement for long-term care services for its patients.
Public hospital systems around the country address the issue of long-term care quite differently.
Some (Chicago, San Francisco, Memphis, New York, Indianapolis) have long-term care beds as

part of their systems. Others, like Parkland, have relied on establishing relationships with long-
term care institutions, whereby the nursing home agrees to take a certain number of unfunded
patients along with the paying referrals. As the population ages and as the demands for acute
care beds intensifies, having long-term care beds as part of the system allows for significant
flexibility to move patients into less costly levels of care. In some systems, these beds have
allowed the acute care hospital to transfer not only the elderly but also disabled trauma
patients, those needing long-term IV antiobiotic therapy, “rule-out tuberculosis” patients and
others who simply need to be confined to a bed for a period of time, though not necessarily in
an acute care institution. This issue has not been a priority for Parkland, although front-line
administrators agree that it is becoming more difficult to transfer patients needing continuing
care out of the hospital and into a nursing home.
The long-term care issue has many facets. Publicly-owned nursing home beds open up
additional opportunity for federal match of local financial contributions to health care services.
Further, there is the opportunity for establishing a partnership with either a current nursing
home provider or with another hospital system to enter into a contractual arrangement. Finally,
the planning for a replacement hospital for Parkland will provide the opportunity for further
assessing the levels of care that need to be built in order to assure that all are operated most
efficiently (if there are long-term care beds in the system, for example, it may decrease the need
for some acute care med/surg beds). This planning is complex but is absolutely essential to
assuring a cost-effective system of care.
Similar comprehensive planning efforts, involving financial, clinical and partnership

assessments should take place for psychiatric services, substance abuse treatment and home
health care.
Disease Management
“Disease management” may seem to be the latest buzz word in the effort to manage health care
in the United States. It is an approach that is a180 degree departure from utilization
management by which managed care organizations reviewed requests for health care services
in an attempt to discover and eliminate inappropriate and excessive use. Disease management
is a strategy designed to find the right clinical intervention for the right person at the right time.

In spite of the many studies of disease management that have been done, the vigorous debates
between academics about its merits, and the numerous vendors offering disease management
packages that have appeared, the definition of disease management used has not always been
consistent. For the ensuing discussion the definition used expresses an emerging consensus of
disease management as the planned and systematic approach to caring for a population of patients with
anticipatable needs and problems, typically defined by a chronic illness or condition.
Importance for the Parkland System. Chronic illnesses, the usual subjects of disease
management programs, make a particularly large contribution to poor health status in the
United States and Dallas County. These conditions include diabetes, asthma, heart disease,
depression, arthritis, and cancer. Increased prevalence and poor control of chronic illnesses are
the causes of the worse health status that minorities and the poor suffer compared to the general
population. Chronic illness accounts for 75 percent of national spending on healthcare. Chronic
health conditions, on the other hand, are not strictly illnesses but are important health issues
that are amenable to disease management and include reproductive health, child development
and health practices such as immunizations.
Review of Parkland’s diagnosis data and its exploding pharmacy program reveal that its
patients have a very high burden of chronic illness. This is the case at all levels of the system,
from the COPC clinics to specialty care, to the walk-in Ambulatory Care Center to the inpatient
units. Most of the chronically ill in the Parkland system are uninsured and, thus, the costs of
their care are ultimately the responsibility of the County subsidy. In addition, the system’s
employees, who receive care in Parkland Health Plus managed care plan, have extraordinarily
high levels of chronic disease. Managing the care of both patients and employees of the
Parkland who have chronic illnesses needs to be viewed as a system priority.
The core strategies in disease management enable clinicians to improve their care of chronic
health conditions through population medicine principles as well as access to timely
information. A population medicine principle, for example, is the identification of every
diabetic in a physician’s practice to assure that each one of them receives an influenza
vaccination at the appropriate time each year. Timely information for a health care provider
might be a warning that the medicine they just prescribed should not be used if the female
patient intends to become pregnant or is even at risk of pregnancy. The best clinical and

population practices change constantly based on new clinical evidence from scientific studies
and national consensus recommendations. In a disease management program, the system
assumes responsibility to provide and advance best practices rather than leave it solely to the
individual practitioner.
Disease management is a particularly attractive approach in that it improves health and patient
satisfaction and, at the same time, is associated with significant cost savings. Recent clinical
trials and disease management programs sponsored by managed care organizations have
demonstrated achievements in limiting complications, improving health measures, reducing
costs, and enhancing the quality of life of the person with chronic diseases. (Disease Management
March 2004, Vol. 7, No. 1, Pages 47-60)
Components for Disease Management. Interviews, direct observation of Parkland operations,

and review of organizational documents and policies reveal that Parkland has made abundant
investment in the components necessary for disease management. Although Parkland Health
and Hospital System currently performs only limited disease management activities, an
appraisal of these management components for an effective disease management program
reveals that Parkland is particularly well positioned and equipped to implement a such an
approach. Disease management components include:
• An identifiable patient population. Parkland has stable populations enrolled in their

various managed care programs including Medicaid patients, employees and
approximately 75,000 medically indigent patients who are enrolled Parkland Health
Plus. Additional chronically ill patients are served in the COPC clinics.
• Parkland’s management information systems should be sufficiently robust to identify

patients and capture required clinical and utilization data as necessary in disease
management. At the present time, Parkland facilities are not uniformly on the same
information system. This is being actively addressed and should be resolved in the near
future The departments of Strategic Planning, Quality Improvement and Decisions
Support are all resources that possess strong data analysis and program improvement
capacities to evaluate and manage data for disease management purposes.

• Evidence-based practice guidelines are protocols for clinical management of various stages
and circumstances of a chronic illness that, when used effectively, improve the health of
patients and limits more costly care. Parkland staff is familiar with and open to
implementing these guidelines and, in fact, certain members of Parkland’s staff are
actually involved in preparing national protocols.
• Patient self-management education/support is a proven method to increase the patients’

ability to care for their own condition. It draws on modern behavioral and educational
techniques to increase self-monitoring, the accurate assessment of the chronic condition,
and assures effective responses by patients. The patient then changes their medication in
response, if necessary. Staff at Parkland’s COPC clinics has begun training in how to
increase self-management. Group sessions, written action plans for patients and goal
setting methods are being introduced.
• Collaborative practice models. Team based health care has been introduced in the COPC
clinics and is in an early stage of development.
• Care Management Services. Parkland employs care managers but the scope of their job is
limited to inpatient care rather than the longitudinal care of a caseload of high-risk
patients.
• Process and outcomes measurement, evaluation, and management with routine feedback.
Parkland has the ability to assess its patient population’s clinical status, physician
compliance with evidence-based practice, patient success with self-management.
Disease Management at Parkland. Actually, Parkland Community Health Plan (PCHP) does
offer disease management through a contract with a private vendor for its Medicaid/SCHIP
enrolled children and the smaller number of adults with asthma in its Health First program.
Although this represents an opportunity to improve the health of children, the resources within
the Parkland system are not used in disease management since Parkland does not provide
specialty or inpatient care for children nor does it provide most of the primary care for Health
First enrollees.
PCHP initially also sought to include Parkland employees and indigent Health Plus members
with diabetes, coronary artery disease, and congestive heart failure in a disease management

program. However, this effort was rejected by the plan’s employee benefits committee. There
are a few less than robust efforts within Parkland Health and Hospitals that might be
characterized as disease management. Several years ago, Parkland invested in what was called
disease management. However, most of the resources were directed to departments that
planned efforts that were isolated from the patients in Parkland’s managed care plans that are
described above, and reflected departmental interests that were often academic in nature. For
example, Parkland’s adult asthma clinic was designed and is operated in such a way that COPC
or other primary care providers in the system have trouble accessing it and rarely refer patients
who would benefit from the more intensive asthma care provided there. There is little
interaction between the “front line” doctors and the specialist who could assist with patient care
decisions. The ED doctors attempt to refer patients to the asthma clinic but new appointments
are distant and asthmatics who are smokers, a high risk group, are excluded. It clearly is not an
important factor in a disease management approach to the large number of persons with
asthma for whom Parkland is the ongoing source of care.
Although the components are present, Parkland does not perform disease management in a
systematic way for several key reasons, including:
• Disease management programs have never been optimally integrated across the system.
• Recognition for health benefits and savings from disease management programs may or
may not accrue to the entity that implements them. For example, COPC clinics could
decrease ED use, but this not measured or considered in resource distribution within the
system.
• The care of indigent patients within Parkland Health Plus is no longer effectively
managed. The indigent are the Parkland patients most appropriate for disease
management. If they generate high costs from complications of chronic illness, Parkland
incurs those costs fully.
• There is no comprehensive commitment to implement disease management across

Parkland Health System. No one person or department “owns” disease management at
Parkland and no one has authority or responsibility for population outcomes.

Implementing Disease Management. A commitment should be made at Parkland to focus on

the management of chronically ill patients in its system, understanding that this effort will have
a positive impact of the health of their patients and the cost of the services provided to them.
This initiative will entail planning and resource allocation to: 1) build information system
capacity dedicated to disease management; 2) redirect and integrate current care management
and quality improvement activities under a comprehensive disease management strategy; 3)
apply selected disease management strategies to the entire systems’ patients and physicians; 4)
distribute the expense and return benefits under an explicit plan; 5) designate leadership and
structure that has authority to implement a full disease management program for the entire
Parkland system, giving priority to the indigent patients and employees who will have the
greatest impact on cost-savings for the system. Initially, this effort should target the most
prevalent and costly chronic medical conditions in the Parkland system, including diabetes,
asthma, hypertension, chronic heart failure, depression, coronary heart disease, HIV, and
reproductive health (including preconception care).
B. The Relationship of Parkland to the University of Texas Southwestern School of

Medicine
History
Parkland and the University of Texas Southwestern School of Medicine (UTSW) grew up
together. Until 1943, Parkland was the primary teaching hospital for Baylor University. When
Baylor left Dallas, a private medical school was formed that would, by 1949, become a public
institution, UTSW. UTSW medical school students rotated through the old Parkland Memorial
Hospital on Maple Avenue from their classrooms in prefabricated huts behind the hospital. The
current Parkland Hospital opened on Harry Hines Avenue in 1954 and UTSW was close behind,
relocating into their current buildings immediately adjacent to Parkland the year after. Parkland
has been the primary teaching hospital for UTSW since its inception and Parkland has looked to
UTSW as the source of its medical staff for over sixty years. Together, they have developed into
one of the country’s preeminent medical schools and on all lists of the best public health and
hospital systems in the nation.

In the 1980s, UTSW was becoming increasingly concerned that its faculty had little or no
opportunity to build a practice of privately insured patients because they had no hospital to
which they could admit them. (The perception, right or wrong, was that these patients would
not want to be admitted to Parkland). In 1989, the University opened Zale-Lipshy, a private
hospital adjacent to Parkland to be used to admit patients seen in its physicians’ private
practices. A decade later, they added St. Paul Hospital, also on the Parkland/UTSW campus, to
further build their private referral practices. Most of the physicians who practice at Parkland
also practice at Zale-Lipshy or St. Paul, depending upon their specialty.
The Faculty Contract
Over the years, Parkland and UTSW have taken significant steps toward making the annual
faculty contract more transparent. As with many public hospital/medical school contracts
around the country, the old approach seemed to be to agree to give the school a set amount of
money every year and assume that this payment would cover the costs of the clinical care
provided in the hospital and its clinics. Also like most other similar relationships, the
partnership between Parkland and UTSW was built almost totally on residents delivering the
vast majority of the clinical service load, with faculty physicians providing nominal
supervision. This arrangement satisfied UTSW’s need to have a training ground for their
students and residents and Parkland’s need for clinical services provided most cost-effectively
to their patients.
Over the past decade, national attention has increasingly focused on assuring both the quality
of resident physician training and the clinical care that they delivered by setting standards for
direct, hands-on supervision by faculty physicians. As in other academic medical centers across
the country, Parkland and UTSW have been struggling with meeting these standards, resulting
in additional UTSW faculty time in both the inpatient and outpatient settings within the
Parkland system. At the same time these structural changes were occurring, the efforts were
starting to be made to assure that the faculty contract accurately reflected the services that were
being provided as a protection for both sides.
It should be noted that, unlike medical schools that have their own hospitals and operate their
own resident continuity clinics, UTSW provides all of its indigent care at Parkland and gets

reimbursed by Parkland for any care provided to the uninsured. In order to be clear about the
clinical care being reimbursed, a decision was made to base clinical reimbursement on a
nationally-recognized payment system, Relative Value Units (RVUs). Faculty would directly bill
any third party coverage for which their patients may be eligible (Medicaid, Medicare,
commercial insurance). Parkland would be billed directly by UTSW for care provided to
patients without any form of coverage.
It was also agreed, primarily because the Texas Medicaid reimbursement rate for physician
services was so low, that Parkland would reimburse UTSW for indigent patients at Medicare
rates. In addition, to help with the transition to this more accountable system, Parkland agreed
to establish a “collar” around the predicted amount of payment to be made to the University for
these RVUs. Thus, no matter how many RVUs were billed to Parkland, UTSW was guaranteed
to never get more than 2 percent less—or more—than the projected amount. This agreement
also protected Parkland from unanticipated budget demands. The guarantee, though, was
meant to be temporary, allowing UTSW to gear up to start billing under this system.
In addition, the faculty contract allowed for a number of departments (primarily, hospital-based
services such as radiology, pathology and psychiatry) to be paid a negotiated rate outside of the
RVU system. These payments were to be based on documentable services provided to
Parkland’s patients. The contract also paid for “performance enhancements” to incentivize both
quality and productivity. Some of these performance enhancements were used to encourage
additional faculty presence in clinics, inpatient units and the operating rooms, behaviors that
shouldn’t need additional payments to assure. Further, the contract provided funding for
“medical director” payments to well over 100 faculty members who played leadership roles of
some kind in the Parkland system, resulting in many physicians who have responsibility but no
identified real authority. It also specifically provides financial support for “stand-by” coverage
for services that require extensive call, and payments for technical services, which originally
covered specific purchased services but now include an amalgam of payments, including those
for staff that should better be included in another, more accountable, contract line.
Despite the lack of any significant service volume increase over the past decade, the value of the
faculty contract increased from $22.1 million in 1993 to $72 million in 2003. Much of this
increase is due to the actual cost of assuring faculty supervision of residents in the Parkland

system, which has significantly increased over the past decade. However, recently UTSW has
not been able to fully document the level of RVUs and the contract “collar” assured that they
remained at the negotiated payment level.
For FY 2005, UTSW requested a major increase in the faculty contract of $26 million—to a total
of $98 million. Again, there has been little or no increase in service volumes, even though part of
the request is to increase the clinical service portion of the contract. A significant portion of the
increase originally requested ($10.8 million) was due to pressures being felt by UTSW to comply
with the requirements of Residency Review Committees (RRCs) to limit resident work schedule
to 80 hours per week. This requirement had gone into place in July, 2003 and has been
accommodated by hospitals and medical schools around the country by staggered scheduling,
additional support staff, heavier reliance on provider “extenders” like nurse practitioners.
Parkland must make the same staffing and scheduling adjustments. Other major increases are
in the areas of non-RVU reimbursed departments and in stand-by coverage.
HMA has participated in numerous sessions with the leadership of both UTSW and Parkland to
review all aspects of the faculty contract. In addition, HMA has reviewed the data submitted by
UTSW that documents what it has determined as its cost of doing business at Parkland
Hospital. It is important to note that contracts in the past were negotiated without the available
cost data and gaining this extra knowledge was extremely helpful in understanding why UTSW
has stated that Parkland was not covering its cost (a loosely defined requirement contained in
the May, 2003 state appropriations bill addressing the responsibility of “institutions of higher
education providing indigent health care to contract with relevant counties in their service area
to recover the costs associated with treating those counties’ indigent patients,” a provision
whose definition of “cost “ has not been tested).
The submitted cost data indicates an extremely high proportion of UTSW expenditures
dedicated to administrative costs of one type or another (more than half of its total cost). The
various overhead payments (departmental administration, residency program operations,
institutional support, etc.) need to be thoroughly scrutinized. These may well represent the
UTSW costs. However, this level of overhead on the provision of clinical services is of
significant concern. Further, the data provides detail on the amount of time per physician spent
caring for patients at Parkland. The hospital’s leadership should review this information

carefully to validate that the amount of time attributed is actually provided, and provided for
the services that Parkland needs and has contracted for. The fact that UTSW has provided this
information is an enormous step toward creating an agreement that is transparent. The next
step will be to assure that what Parkland pays for is appropriate. (See further discussion of the
faculty contract for 2005 under the Finance Section in this Chapter).
Conceptually, as the contract negotiation process moves forward, HMA recommends that the
following issues be addressed:
• UTSW costs that are directly and appropriately attributed to the expenses incurred by
providing services at Parkland Hospital, should be reimbursed.
• Clinical services should continue to be reimbursed on the RVU system (even those not
currently supported that way).
• There should be third party verification of clinical services reimbursed through the
contract.
• The “collar” guaranteeing payment should be based on the previous year’s actual
numbers with a collar of 10 percent.
• Performance enhancements should be targeted to increasing productivity and quality.
• Payments for “medical directors” should be consolidated and targeted to fewer and full-
time physicians practicing at Parkland, with clear authority at the hospital for
designated service areas (i.e., medicine, surgery, critical care, women’s services,
ambulatory care) and at UTSW for faculty issues.
• The contract should be transparent to all of the Departments that provide services in the
hospital and clinics. If dollars are targeted to certain Departments, they should be
assured to go to those Departments.
In addition to these principles for renegotiating the annual faculty contract, Parkland and
UTSW should begin the process of renegotiating the Master Affiliation Agreement, established
in 1979, in recognition of the major systemic changes of both institutions.

Medical Staff Leadership
Parkland has clearly benefited from the affiliation with UTSW as its medical staff is made up of
extremely competent and dedicated physicians. UTSW has also relied heavily on its relationship
with Parkland to develop into a widely respected teaching and research institution. However,
the structure of the clinical services provided at Parkland by UTSW physicians, dictated heavily
by the teaching model where resident doctors and teaching needs of the University are the
predominate concerns, has increasingly serious impacts on the ability of Parkland to effectively
and efficiently respond to the health care needs of its patients. The impact is felt in areas
throughout the system, from the capacity and productivity of the specialty clinics, to timely
discharge from the hospital, to continuity between the COPCs and hospital-based services, to
direct admission to the hospital without going through the Emergency Department. Significant
changes have already taken place in the expectation for attending physician involvement in the
direct supervision of residents; this same expectation needs to be translated into the delivery of
clinical services. This focus is a responsibility of both Parkland and UTSW.
The key issue is now to build upon the truly valuable and vital relationship between the
hospital and the school to move into a different way of approaching the clinical delivery of care.
A critical component of making this transition is having clear, strong, accountable medical
leadership that is responsive to the needs of the physicians and the patient care they are
providing, actively involved in both setting and implementing the strategic direction of the
health system, and that is given authority and accountability at both the medical school and the
hospital over budgets and personnel. It should be the charge of this leadership that the clinical,
teaching and research priorities of the hospital are consistent with the needs of the patient
population that it is charges with serving. In discussions with both Parkland and UTSW
leadership, there was an agreement to move forward on establishing this new cohort of medical
leaders.
Despite the fact that there are many committed physicians at Parkland who view their primary
allegiance to the hospital, they are nearly all on the payroll of UTSW. Most physicians work
substantially in other venues and admit to other hospitals. The Chairs of Departments are
UTSW Chairs, who have responsibilities at several different hospitals. They are faced with
different and often competing missions and expectations from their roles with the hospital and

the University. But the structure within the Parkland system is also discouraging of active
physician involvement in leadership. It is a commonly heard complaint that physicians
practicing at Parkland on both the front lines and in leadership positions don’t know who is in
charge. Many physicians feel as though they don’t have a formal and recognized role in
addressing operational issues in the hospital.
HMA believes that a medical leadership structure needs to be developed with the following
components:
1) a Chief Medical Officer for Parkland, directly reporting to the CEO, with clear authority
over the physicians and medical care practiced in the institution, with a defined role at
the University in addressing the teaching and research aspects of services provided at
Parkland, and with control over budget and policy impacting the practice of medicine
and patient care;
2) medical directors in key areas of the system (e.g., medical services, surgical services,
women’s/infants’ services, ambulatory specialty and primary care/COPC) who are near
full-time at Parkland and have authority over the clinical services in these designated
areas, although it is clearly beneficial for these leaders to have an administrative and/or
teaching role at the University as well;
3) movement toward a dedicated medical staff at the hospital and the system, better
integrating the COPC clinics’ medical staff; and
4) a formal mechanism for involving medical staff leadership in the senior management of
the system, both in day-to-day operations and in setting long term direction.
It is vital that these positions are recruited by Parkland, with participation by the University,
perhaps trading on the enormous reputation of Dr. Anderson in the medical community
nationwide. These positions should include meaningful faculty appointments at UTSW and
roles within the school, while the primary focus should be at Parkland. It would be preferable,
though not absolutely necessary, that these physicians were on the payroll of Parkland.

Long-Term Planning Issues
UTSW has publicly and aggressively moved forward in the further development of its own
clinical services on-site of the Parkland/UTSW/Children’s campus. The issue for this analysis
focuses on the impact of this plan on Parkland, not on the University or on other institutions.
There seem to be several key issues to consider as Parkland looks at its relationship with the
University over the next decade.
First, a clear understanding needs to be established of what constitutes a Parkland patient.

Perhaps out of no ill will to Parkland, it is not uncommon for paying patients who are either
patients in Parkland’s specialty clinics, its Emergency Department or even in its hospital beds to
be admitted or transferred to the University’s Zale-Lipshy or St. Paul’s hospitals. This relocation
out of Parkland is explained as due to patient preference, medical necessity, lack of bed capacity
(documented above for rehabilitation patients), the perception that paying patients are really
UTSW physician’s patients because they are not paid by Parkland to see them or other rationale.
However, non-paying patients are almost never transferred out of Parkland for these reasons. It
is critical for Parkland as it takes on an increasing load of uninsured patients to, at minimum,
maintain the paying patients (particularly Medicare patients) that they have now. As the
University further develops its clinical services at Zale-Lipshy and St. Paul and, ultimately, the
planned new University hospital, the inclinations, however innocent, to transfer patients into
these institutions, will intensify for UTSW physicians. A clear understanding of when transfers
are appropriate needs to be agreed upon, monitored and enforced. The UTSW leadership has
agreed that this could be accomplished.
As the University builds clinical services in its own facilities, Parkland needs to be able to
objectively assess the impact of the UTSW plans on the care of its own patients. If, for
example, the University wishes to build its heart surgery program at St. Paul and all Parkland
patients are transferred there for these procedures, Parkland needs to be able to assess, both
currently and in the long-run, if such an arrangement is economically and clinically appropriate
and beneficial. Or, as the University expands its neonatal intensive care units (NICUs) at one of
its hospitals and at Children’s, Parkland needs to assess the impact on its own NICU, which is
staffed and led by UTSW physicians who may now be stretched to cover other programs. These
are clear long term issues that Parkland and UTSW need to have a formal mechanism to discuss

and resolve, even if that means that Parkland needs to find other medical service arrangements
for certain areas. The University has expressed a willingness to assure that Parkland will be able
to look elsewhere if it cannot meet Parkland’s needs in particular areas, like they did when
Parkland opened the COPC clinics.
Optimally, there should be a commitment to enter into serious discussions about a rational and
collaborative approach to the capital and service development on the campus. While there is
currently a forum for sharing the master facilities planning initiatives between Parkland,
Children’s and the University, there has been little serious discussion about the potential for
collaborating on either building projects (ambulatory surgery, rehabilitation, etc.) or services
(food services, labs, security, etc.). All three institutions are initiated major master facilities
planning efforts and this is a critical time for such collaborations to be explored.
Conclusion
It is without dispute that the UTSW partnership with Parkland is valuable, long-standing and
must be preserved for the mutual benefit of Parkland, the University and the Dallas
community. It must also, however, be remodeled to reflect the clinical, operational and financial
needs of the Parkland system, while still providing the academic benefits for UTSW. This new
approach will require new thinking and new structures from both the hospital and the school.
While the current faculty contract needs to be executed fairly quickly, it is imperative that the
University and Parkland begin the process of renegotiating the Master Affiliation Agreement to
fully address the complex issues related to leadership, clinical service models, teaching and
research priorities and interaction between two clinical enterprises. This is a very different time
and these are all issues that didn’t exist substantially when the agreement was first negotiated
twenty-five years ago. Failing to fully understand and confront them now would be a disservice
to both institutions.
C. The Financing of the Parkland System
The financial health of a public hospital system should be evaluated based on its ability to
accomplish its mission, maintain the viability of its plant, and accomplish this while

maintaining a stable tax rate. The community should have an expectation that the public
hospital system has a financial plan in place that allows for appropriate levels of service to be
maintained in difficult economic times, that the physical facilities are replaced at regular
intervals and updated appropriately between replacements, and that the tax rate is relatively
constant unless extraordinary circumstances arise. Accomplishing this within the constraints of
a patient mix like Parkland’s (49% government-sponsored, 37% charity/self-pay, and 14%
commercial) is challenging. Within this context, HMA identified the following critical success
factors for evaluation:
• adequate leveraging of local tax revenue;
• maintenance of adequate local tax revenue and taxpayer equity;
• operational effectiveness of the Parkland system;
• financial management and information technology;
• contract for medical staff; and
• additional service opportunities.
Each of these issues is discussed below, along with potential opportunities for stabilizing or
increasing revenue, reducing cost and/or improving operations. (Additional information and
supporting documentation is included in the Appendices.)
Adequate Leveraging of Local Tax Revenue
Medicaid is a joint state and federally funded program targeting low-income families, those
receiving cash benefits through other federal programs and low-income elderly and disabled
individuals. In Texas, each dollar spent on Medicaid services consists of $0.61 from the federal
government and $0.39 in state or other local funds. States are allowed to generate their share of
Medicaid payments in a variety of ways, including the use of intergovernmental transfers
(IGTs) from counties and other units of government.
How states leverage local resources in their Medicaid programs is not only a financing issue, it
is a taxpayer equity issue. By not leveraging all available local tax dollars, the burden of paying
for indigent health care is disproportionately borne by the local taxpayer.

Financing Medicaid poses significant problems for states during periods of economic
downturns. Demand for assistance from qualified individuals increases at the same time state
budgets are struggling due to lower tax revenues. Without a strong partnership between local
and state governments, the state may constrict its Medicaid budget resulting in the loss of
federal matching funds forcing the local unit of government to bear the entire burden of
increased demand alone. This places a significant strain on local taxpayers, as people who
previously qualified for assistance from state and federally supported programs must turn to
resources financed solely from local taxes. A creative partnership between local and state
governments works to maximize the leverage of the local financial contribution. In fact, anytime
this partnership is not working, the burden of paying for indigent health care is
disproportionately borne by the local taxpayer. This is the case in Dallas County and Texas
today.
Special Financing Opportunities. As discussed in Chapter One, Dallas County spends

approximately $322 million on low-income health care services, of which $150 million is not
matched. Despite the extensive efforts of the Parkland CEO and other health care leaders in the
community, this money remains unleveraged. HMA believes the only way the County will
receive an appropriate level of Federal participation in low income health care financing will be
based on a strategy whereby political and business leaders address this issue as a taxpayer
equity issue. This increased leveraging is critical if Parkland is to meet the growing needs of the
community into the future at acceptable property tax levels.
There are two issues related to increasing federal participation in low-income health care. The
first is to have a source for the state match. Dallas County has that. Its $150 million of match will
generate $225 million of new federal money. The second issue is to have a State Medicaid Plan
that conforms to federal guidelines and allows for the expenditure of this money.
HMA reviewed the current Texas Medicaid reimbursement system for both fee-for-service and
managed care members and evaluated several options for generating additional Medicaid
revenues. The following represent the most practical options in terms of potential
implementation in Texas in a timeframe of one year or less. These strategies entail no new State
money; they are based entirely on leveraging currently unmatched County tax dollars. Recently,
State Medicaid Plans and related Amendments have come under the scrutiny of the federal

government. HMA believes that the options described below, while requiring negotiations with
Center for Medicaid and Medicare Services (CMS), would be approved. This conclusion is
based on the experience that HMA has had in this area in other states around the country.
• Additional Upper Payment Limit (UPL) Payments. Federal Medicaid regulations limit total
Medicaid payments to what Medicare would pay for the same services for each class of
provider (e.g., non state-owned public hospitals), which is commonly referred to as the
Upper Payment Limit (UPL). Within each class of provider, each facility’s payments are
limited to no more than total charges. Despite a recent increase, Parkland’s charge
structure is still a limiting factor in maximizing UPL payments. Concurrent with an
increase in Parkland’s charge structure, Medicaid UPL payments could be increased.
The final reconciled data is not yet available. Based on current data the maximum is $16
million, but Parkland’s expectation is that this number may actually turn out to be
lower.
• Expanded Eligibility. The State Medicaid agency could take actions to expand Medicaid
eligibility to undocumented immigrants that are pregnant to pay for prenatal care. This
would require a Medicaid State Plan Amendment (SPA) from CMS. Rhode Island,
Illinois, Minnesota, Arkansas, Washington, Massachusetts, and Michigan already have
approved such waivers. This care is currently being provided by Parkland and other
safety net hospitals and paid for entirely by local tax dollars. HMA estimates that this
could yield additional revenue of approximately $7 to $9 million.
• Physician Payments. Increasing Medicaid payments to physicians affiliated with public

entities is a strategy being used in several other states to claim match for local funds and
increase access for Medicaid patients. Texas is exploring this opportunity, but estimates
of its impact on Parkland are not available. However, it is important for the community
to ensure that the benefit accrues to Parkland for its employed physicians and to UTSW
for its faculty. UTSW has indicated that if it received additional Medicaid funding
through these enhanced payments its need for funding from Parkland would be
reduced.
• Medicaid HMO Rates. Federal regulation requires Medicaid HMO rates to be set based on
principles of “actuarial soundness.” However, broad discretion exists in defining this

term. Clearly, the Parkland HMO enrolls a different mix of patients than other Medicaid
HMOs in Dallas. The State has explored adjustments in rates based upon the severity of
patient needs. These criteria, along with arguments for expanded access to care, could
easily justify increased capitation payments to Parkland’s HMO, which could be used to
benefit the hospital and/or the physician groups affiliated with the hospital. Improving
the Medicaid fee-for-service base payment rate (the basis on which Parkland’s HMO
rates are set) would assist this process. HMA estimates the potential impact on Parkland
to be approximately $5.6 million, assuming a 5 percent increase in premiums.
• Charity Care Funding. The community could establish a 501 ( c)(3) entity to fund charity
medical care in Dallas County. This entity could legally receive contributions from
private hospitals that wish to alleviate pressure on their emergency room by promoting
access to appropriate health care services for uninsured. The private hospital contributes
to the not-for-profit entity that, in turn, funds health care for uninsured patients at
Parkland and other entities in the community.
• Private Providers. Dallas County can pay the state share of Medicaid UPL payments to
the private DSH hospitals in Dallas County. HMA estimates that the available UPL
capacity of these private DSH hospitals in Dallas County is approximately $412 million
($179 million if Children’s Medical Center is excluded). In fact, this strategy could
absorb the entire $150 million of unmatched local tax dollars.
Converting COPCs to Federally Qualified Health Centers (FQHC). Parkland can significantly
improve the financial position of its COPC clinics by converting them to Federally Qualified
Health Centers (FQHC). FQHCs receive cost-based reimbursement for Medicaid fee-for-service
and managed care patients and are also eligible for other benefits, including drug pricing
discounts, “first dollar” Medicare reimbursement, and, in the case of Section 330 grantees,
federal grant funds to support the costs of providing uncompensated care. It has been
determined that the Parkland COPCs already meet most of the requirements for FQHC
designation and would only have to adjust to the governance guidelines for public sector
FQHCs.
HMA analyzed Parkland’s cost reports to estimate the net impact of cost-based reimbursement,
assuming FQHC status. The analysis indicates that Parkland could receive an additional $9.3

million in annual Medicaid reimbursement under an FQHC model for their current COPC clinic
operations.
Table 8
COPC Under FQHC Reimbursement
(Dollars in millions)
FY 2003 COPC FQHC
Medicaid FFS Payments $3.0 $6.3
Medicaid Managed Care Payments $4.3 $13.6
UPL Payments $2.7 $0.0
Professional fees $0.6 $0.0
Total Payments $10.6 $19.9
*Source: HMA analysis of Parkland cost reports
Maintenance of Adequate Local Tax Revenue and Taxpayer Equity
HMA subcontracted with an independent economic analysis firm – Texas Perspectives, Inc.
(TXP) – to assess the long-term financial health of Parkland given demographic and economic
trends in the region (see Appendices for complete report). TXP’s analysis shows that, in the near
term, Parkland’s local tax revenue is adequate to support its uncompensated care costs. Within
the next three to seven years, however, uncompensated care costs will equal and eventually
exceed tax revenue at the current rate of ($0.254 per $100 of assessed value).
This timeline is accelerated when the Medicaid shortfall (Medicaid costs minus Medicaid base,
DSH and UPL payments) is taken into account. Currently, Parkland’s tax revenue is supporting
its uncompensated care and also compensating for poor Medicaid payment rates that fall far
short of costs. The County will not be able to continue subsidizing Medicaid payments at the
current tax rate. This supports the need to capitalize on existing opportunities to maximize
available matching funds as detailed above, both as a means of protecting the long-term
financial health of Parkland and as a matter of taxpayer equity.
While a stable tax rate is a reflection of Parkland’s financial health, it also has a direct impact on
its financial health. There will be years when revenues are particularly strong due to unforeseen
changes in reimbursement, settlement of past cost reports or lawsuits, or other factors. These
positive financial results do not by themselves justify lower tax rates or new responsibilities
unless Parkland’s Board-approved capital plan shows this money is not needed for anticipated
plant and/or equipment needs or to maintain a cushion for leaner years. By allowing the

institution to develop reasonable reserves in accordance with a Board approved plan,

management will be encouraged to act with long-term goals in mind, which further protects
taxpayers from future tax rate increases.
Out-of-County Care Provided By Parkland
Out of County care has been the subject of much recent media attention in Dallas County. While
this is an important equity issue for the region, HMA’s analysis shows that the dollars involved
are not of the scale of some of the other issues discussed in this chapter. Nevertheless, it is an
issue that requires a sustainable, long-term solution. Table 9 presents a per capita comparison of
indigent care expenditures in Dallas County and the surrounding counties and illustrates the
inequities in the current system.
Table 9
Out-of-County Care – Per Capita Comparison
Indigent Care
Population Indigent Care Indigent Care Expenditures as % of
(2000 Coverage Level 2003 Indigent Care Expenditures General Revenue Tax
County Census) (as % of FPL) Expenditures Per Capita Levy (GRTL)
Collin* 491,675 25% $ 2,147,573 $4.37 2.60%
Dallas 2,218,899 200% $285,236,000 $128.55 NA
Denton 432,976 21% $1,649,463 $3.81 3.94%
Ellis 111,360 21% $703,172 $6.31 4.19%
Johnson 126,811 21% $1,765,887 $13.93 12.70%
Kaufman 71,313 21% $45,966 $0.64 0.46%
Rockwall 43,080 21% $99,633 $2.31 1.06%
Source: 2003 County Indigent Health Care Program Summary, Texas Department of Health
*Collin County finances indigent care through a foundation, not through tax revenue. Source: Collin County
Parkland provided approximately $81 million in care to out-of-county patients in FY 2003,

including both funded and unfunded patients, as summarized in the following table.
Approximately three-quarters of the costs incurred for unfunded patients came from patients
who were admitted through the Emergency Department or were considered “unavoidable” by
Parkland, meaning that they required a service that only Parkland could reasonably provide.
Parkland lost $10.1 million in 2003 on unfunded out-of-county patients, but only $2.5 million of
this was considered “unavoidable” by Parkland.
The above calculations were based on full cost, which is comprised of the direct cost of the
services provided and a proportional share of overhead (items such as building depreciation,

utilities, administration). Contribution margin is another way of looking at the impact of this
activity. It is based on direct cost only. The contribution margin for unfunded out-of-county
care was a negative $3.8 million, but the overall contribution margin for all out-of-county care,
including the care provided to funded patients, was a positive $17.1 million.
Interestingly, Parkland also incurred significant losses on its out-of-county funded patients,
particularly those covered by Medicaid. In fact, Parkland loses more on Medicaid-funded out-
of-county patients than on “avoidable” unfunded out-of-county patients ($4.7 million versus
$2.5 million). The current Medicaid reimbursement situation in Texas, as well as opportunities
for enhancing Medicaid revenue, is discussed elsewhere in this report.
Table 10
Parkland Hospital Out-of-County Care At Full Cost (FY 2003)
Total
Payments
(including Contribution Excess/
Direct Cost Total Cost allocation) Margin (Shortfall)
Out-of-County Unfunded $8,366,975 $14,662,287 $4,555,241 ($3,811,734) ($10,107,046)
Admitted Through ER $6,076,389 $10,648,263 $3,495,727 ($2,580,662) ($7,152,536)
Other Unavoidable $343,126 $601,294 $169,891 ($173,235) ($431,403)
Total Unavoidable Unfunded $6,419,515 $11,249,557 $3,665,618 ($2,753,897) ($7,583,939)
Remaining Unfunded (avoidable) $1,947,461 $3,412,730 $889,623 ($1,057,838) ($2,523,107)
Out-of-County Funded $38,010,192 $66,625,290 $58,895,057 $20,884,865 ($7,730,233)

County Indigent $204,665 $357,386 $264,852 $60,187 ($92,534)
Medicaid $16,227,518 $29,125,314 $24,458,217 $8,230,699 ($4,667,097)
Medicare $5,449,084 $9,394,282 $7,437,134 $1,988,050 ($1,957,148)
Other $16,128,925 $27,748,308 $26,734,854 $10,605,929 ($1,013,454)
Total Out-of-County $46,377,167 $81,287,577 $63,450,298 $17,073,131 ($17,837,279)
Source: HMA analysis of Parkland Hospital data
The imbalances of the current system require a long-term, equitable solution that is both
politically and economically feasible. HMA discussed this issue with commissioners from each
of the counties surrounding Dallas County to assess the readiness to move toward a regional
system. Several counties expressed a willingness to consider contributing to a Regional Trauma
Network to finance out-of-county trauma care. Several counties also expressed interest in using
their current indigent care expenditures to leverage federal matching funds to finance indigent
health care. The counties generally did not react favorably to mandates requiring a minimum
expenditure (e.g., 8%) of their General Revenue Tax Levy (GRTL) on indigent care, as has been
proposed in the past.

Table 11 illustrates the potential impact of leveraging current county expenditures to generate
federal matching funds, as well as the impact of matching county funds assuming an 8 percent
GRTL mandate.
Table 11
Impact of Medicaid Leveraging of County Funds
CIHCP
2003 CIHCP Spending if 8% GRTL if
County Spending Matched at 60% 8% GRTL Matched
Collin $2,147,573 $5,368,933 $6,620,546 $16,551,365
Denton $1,649,463 $4,123,658 $3,349,935 $8,374,838
Ellis $703,172 $1,757,930 $1,342,631 $3,356,578
Johnson $1,765,887 $4,414,718 $1,112,588 $2,781,470
Kaufman $45,966 $114,915 $801,298 $2,003,245
Rockwall $99,633 $249,083 $636,582 $1,591,455
TOTAL $6,411,694 $16,029,237 $13,863,580 $34,658,951
Operational Effectiveness of the Parkland System
HMA devoted fewer resources to this topic relative to other issues under the scope of this
report due to the large amount of work that has already been done in this area by other
contractors. In addition to identifying areas for improvement, outside contractors are often
brought in to serve as catalysts for change that would be difficult to affect from inside the
organization alone. HMA’s limited review of Parkland’s financial performance indicates
expenses have been controlled and lowered in some cases. It is important to note, however, that
at least one of the initiatives identified has resulted in far less revenue than was reported.
Parkland’s internal auditor reviewed the Denial Management initiative for purposes of
validating the $8 million reported improvement over the baseline. The auditor found that the
baseline appears to have been overstated and, as a result, the net reduction in denials was also
overstated. In fact, their findings indicated there were no increases in net revenues. Parkland
management and its Board are currently working through this issue with the contractor.
The following discussion touches on additional areas of potential financial improvement in the
Parkland system, beyond those described above.
Operations/Revenue Cycle Improvements. HMA was asked to conduct its own revenue cycle
analysis to identify additional opportunities for improving cash collections. ESI performed this
work (see Appendices for complete report). The evaluation included the financial operations for

inpatient services, the emergency department, outpatient specialty clinics and the COPC clinics.
ESI interviewed more than 20 individuals with direct involvement in Parkland’s revenue cycle,
including individuals in finance and administration, as well as in clinical areas. Both “front-
end” admissions and registration and “back-end” billing and collections were observed. ESI
also performed significant analysis of financial and receivables data.
Table 12 summarizes the revenue cycle opportunities identified, which total $6 to $8 million in
potential new revenue. The recommendations focus primarily on front-end process
improvements to qualify more eligible individuals for coverage and build upon improvements
already made in increasing collections at the time of service.
Table 12
Revenue Cycle Opportunities
Process Goal Opportunity
Convert patients to funded sources by
evaluating and implementing
Convert approximately $20
technology to support the enrollment
million more gross charges to a $4 - $5 million
process into funded sources and to
funded source
support improved identification of
patients, addresses, and eligibility.
Implement a stronger denial
management and collections strategy. 10% to 15% reduction in
There is still room to improve approximately $10 million in FY $1 - $1.5 million
collections by focusing resources 2004 write-offs
toward the highest dollar accounts.
Improve time of service collections
through enhancing participation by Increase in clinic related time-
clinical staff and fostering a sense of of-service cash by raising to $1- $1.5 million
responsibility toward the taxpayer internal best performing levels
among all staff.
While revenue cycle operations are relatively strong, two areas were identified as a concern.
First, certain co-pay policies would appear to be counter-productive to the overall goals and
good of Parkland as a system. Relatively large co-pays and restrictive eligibility for reduced fee
programs (including the policy that refuses reduced fees to those who work for employers who
offer health insurance, no matter what the cost to the employee) at the COPCs may be driving
patients to seek care at more expensive Parkland venues, such as the Emergency Department.
We would recommend these policies be reviewed and a fiscal impact study be prepared for the
Board for their action. The other area of concern is the significant number of accounts in the
receivables of the hospital, especially the COPCs, many of which are over a year old. HMA/ESI
was advised that the balances in these accounts were mainly comprised of adjustments and

other write-offs never completed (some five years old). While the financial impact may be
minimal, this is a poor business practice and should be corrected.
As part of longer-term planning, Parkland should also begin to consider the mutual benefits of
a combined revenue management entity that combines the hospital and the medical school
revenue management processes, including medical records, billing and collections.
Pharmacy Opportunities Under the Medicare Modernization Act (MMA). Parkland pharmacy
represents approximately $80 million of Parkland’s overall $820 million budget (FY05 budget
request). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA) provides several opportunities for safety net providers like Parkland (see Appendices
for a more detailed discussion). Members that currently receive drugs through Parkland Health
Plus will either access their medications at Parkland or off site at a local pharmacy. Either
scenario benefits Parkland in terms of reduced exposure to a cost pressure. The potential
opportunities are summarized below:
• Drug Discount Subsidies. From June, 2004 through December 2005, beneficiaries below
135 percent of FPL who do not have private or Medicaid drug coverage will have $600
per year for drug expenses. Parkland estimates the target population (Medicare
recipients not enrolled in Medicaid) to be approximately 4,900 individuals. If 25 percent
of the 4,900 eligibles are enrolled with a discount drug card, this will save Parkland up
to $1.1 million. The impact of the subsidies could be as high as $5.9 million (through
December 2005) depending upon federal enrollment provisions and how the Discount
Card will be integrated into Parkland Health Plus (PHP) eligibility.
• Low-Income Assistance. Medicare will provide additional low-income assistance

beginning on January 1, 2006. Whereas the majority of beneficiaries will have substantial
cost sharing responsibilities beneficiaries with incomes below 150 percent will have their
premiums subsidized. The estimated maximum potential impact of the low-income
assistance program on Parkland is $5.8 million, assuming a total eligible population of
5,800.
• Mail Order –It is clear given the current mail order volume, the current refill level (57%)
that mail order pharmacy, a central refill station, or a combination of the two are an

important consideration when moving forward. As noted elsewhere in this chapter, the
VA is widely respected across the country for its efficiency and quality assurance in the
implementation of a pharmaceutical distribution system, particularly in the area of mail
order prescription refills. Recently, the North Texas VA has doubled its capacity for
taking on additional business and would be interested in collaborating with Parkland in
more efficiently providing refill medications for its patients.
Managed Care Opportunities. HMA conducted a review of the Parkland Community Health
Plan (PCHP), Parkland’s Medicaid and SCHIP HMO, to determine whether opportunities exist
for operational and financial improvement. Parkland has contracted with Aetna to provide
administrative services for PCHP. Among the key findings from this review are:
• PCHP generated a total loss of $4.0 million in 2003 ($6 million loss for Medicaid and a $2
million profit for SCHIP).
• Administrative costs for both the Medicaid and SCHIP plans are increasing sharply and
now stand at 15 percent versus the industry standard of 12 percent.
• PCHP pays non-participating providers 100 percent of billed charges.
• All participating primary care physicians are paid a $3 per member per month
“gatekeeping fee” to manage care.
The review also identified several data and systems limitations at PCHP:
• Aetna provides comprehensive data files to PCHP, but extensive data analysis is
required to obtain relevant, useful and actionable information.
• Budgeting, financial and utilization reporting are performed at aggregate and gross
levels with limited ability to drill down to cost, quality and utilization drivers or
perform root cause analyses.
• There is no provider profiling capability.
Based on these findings, HMA makes the following recommendations for improving PCHP’s
operations:

• Reduce administrative costs to industry standard of 12 percent of revenue. This will

generate approximately $3.7 million in savings. HMA understands that the U.S.
Department of Health and Human Services Office of the Inspector General (OIG) will be
conducting an audit of the administrative costs of all Medicaid managed care plans in
the current fiscal year. PCHP’s current administrative cost structure will not be viewed
favorably in this review.
• Renegotiate provider contracts to pay Medicaid rates, generating approximately $1.5

million in savings.
• Eliminate the current $3 primary care “gatekeeping” fee and replace it with an incentive
pool for primary care physicians that see a large volume of PHCP patients and/or are
effectively managing their patients’ care. The elimination of the current fee would save
approximately $2 million, some of which would need to be used for the incentive pool.
• Retain a contingency-based claims auditing organization to cover incorrectly paid

claims. Estimated savings are approximately $500,000.
• Reduce SCHIP payments to non-participating providers, yielding potential savings of

$500,000.
In addition to the opportunities outlined above, PCHP should consider the development of a
data warehouse and decision support system (including provider profiling capabilities) to help
it identify cost, utilization and quality drivers.
Financial Management and Information Technology
Over the past year, Parkland’s finance department has been largely rebuilt, both in terms of
leadership and systems. Despite recent improvements, including the implementation of a
powerful decision support system, some financial systems remain antiquated, particularly
patient accounting. Outdated systems and a change in financial leadership have caused most of
the effort and vision to be internally focused, leading to progress on internal problems.
Nevertheless, there continues to be room for improvement. During this time of transition, it is
extremely important that Parkland’s financial and operational leadership review all publicly
released financial information for accuracy, consistency and reasonableness. This may increase

the time required to get important information to the Board and ultimately to the Court, but it is
imperative this extra time be taken to ensure decisions are based on the best available
information.
During HMA’s interviews and analysis, the lack of long-term business and financial planning
was apparent. Parkland does not have a current capital plan, its IT plan ends in the current
fiscal year, and there is no current long-term business or strategic plan for the health system.
These factors make it extremely difficult for the Board to evaluate new opportunities or current
progress in any meaningful way. These types of plans are needed to help the Board understand
and set important policies and evaluate capital and cash needs. While the development of these
plans is not the responsibility of the finance department alone, it is imperative that the financial
leadership devote time and energy on collaborating with the medical and operational
leadership to drive their development.
Also of critical importance to Parkland’s financial future is its ability to look outward and
develop and implement major revenue generation efforts through UPL, DSH and other
mechanisms. It was apparent during HMA’s review that these issues were not getting the
necessary attention from a finance team that is mired in day-to-day operations and systems
overhauls. It was also apparent that the financial leadership is not always on the same page as
the operational and clinical leadership with respect to these strategies as well other issues of
critical importance to Parkland’s financial health. It is important that all members of the
leadership team understand the financial and operational implications of decisions. More time
spent in strategic discussions among this group is needed.
The following sections provide a brief discussion of several key financial management issues
examined by HMA. These include information technology, maintenance of plant viability, and
cash balances and capital formation.
Information Technology. As noted above, Parkland is in the final stages of implementing a

new patient registration system that will standardize these functions across the hospital and
clinics. Parkland also recently implemented a powerful decision support system known as T2.
While some data refinements are needed to make T2 function at optimal capacity, the system

has the potential to significantly enhance Parkland’s ability to analyze its operations and service
lines.
The major shortcoming identified in Parkland’s information technology efforts is a lack of a

long-range strategic plan and a corresponding IT plan to support it. While Parkland has made
significant IT improvements in recent years, much of that progress has been out of necessity,
and there is still a considerable amount of work remaining. The Board needs to be given the
opportunity to understand the ongoing IT needs and assist in prioritizing them based on
Parkland’s business objectives.
Maintenance of Plant Viability. The average age of the Parkland plant exceeds 10.5 years. This
is significantly over optimal industry standards. Parkland should attempt to lower the average
age of the plant to 8 years or below as soon as practical, an effort that will require a
comprehensive capital plan. Older average age of plants often indicate that higher operating
costs exist due to obsolete equipment or plant designs that do not optimize how medicine is
currently practiced. It may also indicate significant future capital outlays that may be crippling
from a cash flow perspective if not planned for.
Cash Balances and Capital Formation. The availability of unrestricted cash is a concern at
Parkland. Cash and short term investment balances at Parkland net of amounts for incurred but
not reported claims from the managed care plan and those restricted for capital should be
monitored and efforts made to rebuild them. This is the short-term concern. The long-term
concern is the lack of a capital plan. Parkland should have a Board approved capital plan in
place. This plan should be composed of sources and uses of cash over the next five years. This
will assist the Board in decisions regarding when to pay cash for long-term assets and when to
borrow. It will also provide important information in the decision making process and the
impact of those decisions on capital planning and tax rate implications.
Health care is a capital-intensive business. Parkland has little debt, which is normally positive.
But when coupled with low cash reserves and an aging plant, a low debt burden loses some of
its luster. A capital plan should highlight potential opportunities and risks well in advance to
assist management and the Board in informing the Court and other appropriate parties of their
position and needs.

Contract for Medical Staff
In all negotiations, the symbiotic relationship between Parkland and the medical school must be
remembered. The quality and cost of care at Parkland are in large measure determined by the
faculty of UTSW. Parkland needs to have a strong working relationship with these physicians
based on mutual respect and fair treatment. Parkland should actively support the medical
school’s efforts to enhance payments from third parties, including the State of Texas for medical
education and the state Medicaid program for care of patients. Parkland’s Board has currently
budgeted $77 million for this contract for 2005. Based on our analysis of the contract, as well as
cost data provided by UTSW, this is not an unreasonable amount. However, if additional
services are needed by Parkland, an increase may be warranted.
As soon as possible, negotiations for the 2006 contract should be initiated. The focus of this
effort should be to produce an easy-to-understand, transparent, and verifiable agreement. The
completion of this negotiation by May 1 will allow the Board to thoroughly understand it and
include it in the budget process from the beginning. This should allow the management, the
Board, and the medical school to know the exact amount and its impact on the budget in early
summer and come to an agreement. This will also assist the medical school in recruiting the best
available physicians for Parkland in the number and specialties required.
Cost of Services. UTSW approaches this contract from the perspective of their business need,
which is to recover their costs for providing services at Parkland. In response to HMA’s request,
the medical school shared its departmental cost data. Based on their internal calculations, total
costs for services provided to Parkland are $93 million, not including an add-on for technical
services. This figure includes approximately $48.3 million in total physician costs, net of
collections (HMA imputed an amount for reasonable collection expenses), based on HMA
analyses of the UTSW data. The remaining costs consist of residency administration, other
departmental costs of the Medical School and administrative overhead. Specifically, they
include:
• $9.6 million for the costs of administering the residency program. The residency
program is a UTSW residency based at Parkland for the majority but not all of the
residents. According to UTSW, this figure represents the total costs of administering the

residency program (excluding pediatrics at Children’s Medical Center), not just the
portion directly attributable to Parkland.
• $23.1 million in departmental costs, including billing and collections, other staff and
supplies attributed by USTW to activities at Parkland.
• $10 million in institutional overhead of the UTSW, which represents the school’s
estimate of Parkland’s share of this cost.
While it is certainly reasonable to expect that Parkland should contribute to departmental costs,
as well as some institutional overhead and administrative costs of the residency program, the
question is how much. For example, it does not appear reasonable for Parkland to bear the
entire financial burden of the UTSW residency program when this program trains physicians
for the benefit of the entire state of Texas. UTSW maintains they have no place else from which
to recoup this cost. This is also true of departmental and institutional overhead costs. Parkland
and UTSW should begin working together to find strategies to both reduce these costs and find
appropriate alternative revenue sources.
Analysis of Current Contract. In recent years, steps have been taken to make Parkland’s
contract with UTSW more transparent and accountable. Under the contract, clinical services for
uninsured patients are reimbursed on a relative value unit (RVU) basis, with a “collar” that
effectively guarantees reimbursement at a specified level even if actual RVUs are much higher
or lower than anticipated. Most services are reimbursed at the Medicare rate, commonly known
as the conversion factor, though some (anesthesia and radiology) are reimbursed at much
higher rates based on the rationale that the market rate for these services far exceeds Medicare
rates. In addition, the contract includes reimbursement for some services that are not
reimbursed on an RVU basis, as well as performance-based payments, payments to support
administrative costs, and payments for stand-by coverage. Finally, the 2005 UTSW request
includes an additional $10.8 million for additional staff to compensate for the effects of the 80-
hour rule.
It is important to note that some of the medical school’s request and budget methodologies
reflect a need to subsidize low payments for physicians from Texas Medicaid in addition to
covering the costs of uninsured patients. The faculty treats a disproportionate number of these

patients making a subsidy necessary. HMA’s recommendations do not fully reflect the subsidy
necessary. As a point of reference, in another Midwestern community the state determined that
to equitably compensate faculty physicians for their disproportionate Medicaid mix the
payment rate had to be increased from 28 percent of charges to 64 percent of charges.
The total faculty contract request from UTSW for FY2005 is $98 million. The following table
outlines each component of the request and HMA’s recommendation. HMA’s recommendation
in each area is based on what it views to be good business practice. In fairness, when HMA
reviewed the document, each segment of the contract was reviewed in isolation and on its
merits. The original contract, however, was based on the perception at the time of the whole
cost of doing business and those costs were then delegated to certain categories.
HMA’s recommendation for the RVU portion of the contract is based on 2003 volumes, which
are the most recent actual, although not independently verified, figures. It is further
recommended that a wide collar be applied to allow for any variations above or below this
estimated number. To ensure that payment is based on actual volumes, and that all monies that
can be collected from other payors are collected, it is critical that third-party verification of
claims be reinstated. The vendor selected should assist the medical school in re-billing accounts
that have third-party coverage.
Despite the fact that HMA’s review of the components of the contract reaches a lower number,
this transition year between the old and the new contract, justify the Board’s approved number
of $77 million. During this year, Parkland and UTSW need to work together to try to reduce the
administrative overhead costs documented by the University which HMA views as high.

Table 13
Faculty Contract Analysis
(Dollars in millions)
2005 HMA
Provision 2004 Request Recommendation Discussion
Support of this magnitude has not been seen
80-hour rule $0 $10.8 $0 in other venues; need for support and ancillary
staff is more critical.
HMA recommends a 33% “collar,” from $22
Range of $22.0- million to $44 million, which affords some level
RVUs $32.6 $46.0 of protection to both parties while also
$44.0
reflecting actual utilization.
Mid-level
deduction and ($4.4) ($4.4) ($4.4) No change recommended
concurrency
HMA concurs with Parkland’s analysis of this
Non RVU $12.9 $14.5 $14.4 provision.
Administrative fees should be more targeted
Administration $9.4 $11.0 $10.0 and tied to specific job descriptions and
performance criteria.
HMA’s review of the contract revealed that
many of the performance-based payments are
Performance
$8.4 $8.8 $6.8 for activities that could reasonably be
Standards considered basic job performance. Our
recommendation eliminates these payments.
Stand-by HMA concurs with Parkland’s analysis of this
$2.2 $5.7 $3.1 provision.
Coverage
Program Removed new ED position, which should
$1.3 $2.4 $1.8 generate RVUs.
Enhancements
Several components of this section were not
“technical” in nature and reflect clinical staff or
Technical $3.6 $3.6 $2.8 lab services that should be generating RVUs.
These components were removed in HMA’s
recommendation.
Range of $56.0
TOTAL $66.0 $98.4
to $78.0
Additional Service Opportunities
HMA identified several service areas that warrant further research to determine operational
feasibility and potential for revenue generation. These, listed from highest probability of success
to lowest, include rehabilitation, long-term care, and psychiatry. These services have been
successful at other public hospitals, and the chances of success are further enhanced if the
public hospital can enter into a joint venture to build the service. Despite a strong potential for
success, none of these opportunities should be pursued prior to the development of a
comprehensive business plan that assesses the likelihood of success given Parkland’s payor
mix, partnership opportunities, and the Dallas marketplace.

Conclusion
Parkland continues to achieve its mission of providing health care services to the underserved
of Dallas County, but this mission may be in jeopardy if it fails to adequately plan for the future.
Parkland’s current tax rate is adequate to support the provision of indigent care. However, its
physical plant is aging, and the hospital lacks a strategic plan and a capital plan, which are
needed to ensure the stability of future tax rates. Parkland has undergone substantial leadership
changes within its management structure in recent years, which has led to some noticeable
improvements, particularly in the area of cost reductions, but has also created a lack of
cohesiveness at the very top of the organization – a problem that is exacerbated by the lack of a
permanent Chief Operating Officer.
Parkland’s relationship with the medical school continues to be a critical operational and
financial issue. While this report contains specific recommendations for the 2005 contract, work
should begin immediately on ensuring that the process for the 2006 contract produces an easy-
to-understand, transparent, and verifiable agreement in a timeframe that allows it to be
incorporated into the budget process.
Financial stability could be greatly enhanced by maximizing opportunities to leverage local tax
dollars to secure federal matching funds. Parkland currently has approximately $150 million in
local tax dollars that are not being matched. This is not just a Parkland budget issue, it is a
taxpayer equity issue, as Dallas County taxpayers shoulder a disproportionate share of the costs
of treating uninsured patients. The unwavering support of the County Commissioners and the
local business community will be needed to garner state cooperation in leveraging these local
funds.
Finally, there are several additional service opportunities that should be carefully evaluated
both in terms of operational feasibility and likelihood of financial success. These services have
been successful at other public hospitals, but no action should be taken without the completion
of a comprehensive business plan.

D. The Physical Facilities Challenges for the Parkland System
Over the past several years, there has been a significant amount of work done on the evaluation
of current Parkland facilities and the development of a master plan for their replacement. There
have been numerous reports prepared, some presented to the Dallas County Hospital District
and shared with the Dallas County Court. Land has been purchased and schematics developed
for replacement facilities for the services currently provided at Parkland Hospital, projecting
into the future.
Moving Forward on a Capital Master Plan
The discussion of the facilities Master Plan has been effectively tabled for the past year, except
for a discussion about moving forward on the Ambulatory Surgery Center. HMA urges that a
thorough evaluation of the facilities needs of the Parkland system be reopened and the
development of a capital plan for the system become a priority for the following reasons:
1) There are capital projects for the current facility that should be reviewed now, regardless
of the long-term plan for the replacement of the hospital, which could take a decade to
complete. For example, there is the potential for renovating several units within the
hospital (if an accommodation can be reached with Children’s Medical Center, which is
currently leasing the space for storage) to expand rehabilitation capacity. Further, the
potential renovation of some administrative space in the ED to allow for observation
beds could significantly address some of the bed availability issues. Neither of these
projects has an excessive price tag but both could result in significantly more efficient
operations and/or revenue generation opportunities.
2) The longer that a replacement facility is put off, the more it will ultimately cost, both in
actual replacement dollars and in expenditures on maintaining the current plant. For
example, by the time that the replacement Cook County Hospital was built in Chicago, it
was estimated that the new hospital would cost approximately $440 million less in the
first five years than continuing to maintain—and meet code for—the existing facility.
Parkland has significant facilities problems that, unless there is a commitment to a new
facility in the next several years, will likely require significant investment to maintain its
accreditation. If it was decided that a replacement facility or facilities would be built,

there are some major capital projects that could be deferred. If no decision is made, large
investments will need to be made in infrastructure simply to stay in compliance. Internal
estimates by Parkland’s facilities management leadership indicate that $120 million
would need to be spent over the next 5-10 years if there was no commitment to a new
facility if the implication is that the current buildings will need to be maintained. If there
is a plan to replace Parkland in the next decade, approximately $90-100 million of that
investment could be eliminated, also according to Parkland’s internal estimates.
3) There are issues of size, location and scope of services that need to be re-explored and
that cannot be accomplished until the discussion is reopened and sanctioned by the
Board. There has already been internal work done on the projected size (for example, a
reduction of about 125 beds now amends earlier projections for the women’s and infants
services for the WISH facility, based on revisions in utilization estimates). In addition,
other scenarios are being contemplated, including a smaller, tertiary hub hospital on the
central campus supplemented by decentralized facilities providing different services in
other areas of the County. Finally, the scope of the current operation may need to be
amended to address the changing demographics and methods of providing care (i.e.,
more outpatient specialty, long-term care capacity) that could have an impact on the
acute care inpatient needs of a replacement facility. These are issues that should be
discussed and analyzed as soon as possible.
4) There should be a comprehensive approach to the financing of capital projects once

there is a plan in place. Currently, financing strategies appear to be developed in a
disjointed fashion and may actually result in more expensive building projects. For
example, it is widely felt that the current thinking about building two replacement
hospitals—an acute care hospital and the WISH hospital—will make better sense
because it may be politically expedient to finance them separately, even though building
and operating two different facilities may cost more to construct and to operate
(estimates range from $20-40 million more in construction costs alone, and operating
costs would be significantly greater). Decisions about financing (revenue bonds, cash,
general obligation bonds, etc.) should follow the agreement on an overall master capital
plan.

5) The potential for partnerships with other providers for component parts of the overall
system replacement plan should be thoroughly explored, whether those partners are on
campus or elsewhere. Potential collaboration exists with UTSW, Children’s Medical
Center, private hospitals and the Veteran’s Administration in such areas as
rehabilitation services, long-term care, inpatient psychiatric care, low-risk deliveries,
outpatient specialties, and other discrete service lines.
Next Step: A “Blue-Ribbon” Panel
Part of the current impasse preventing forward movement in the development of a capital plan
for Parkland appears to be a lack of trust between the Commissioners Court, the Dallas County
Hospital District Board and the Parkland administration. There is a lot of money at stake and
decisions about facilities replacement require firm and defensible information. In order to break
the current logjam, HMA recommends that the Dallas County Commissioners Court and the
Dallas County Hospital District jointly appoint a “blue-ribbon panel” made up of local hospital,
civic, and business leadership, who are charged with working with Parkland administration to:
• assess the current facilities issues and prioritize current projects;
• come to a conclusion about the need for a replacement facility, building on information
contained in existing consulting reports so as not to duplicate effort;
• request and review documentation on current and future demographic projections;
• explore the potential for provider partnerships on campus and with other entities in
Dallas County;
• make final recommendations on the elements of the capital plan;
• develop a financing strategy; and
• provide ongoing oversight to any resulting project as it moves forward.
This model of an independent oversight body was utilized in Chicago as the Cook County was
anticipating the replacement of Cook County Hospital. The committee was chaired by a
prominent businessman, and its membership included key private hospital CEOs, and other
business leaders and civic representatives. The committee took it upon themselves to

commission a major consulting firm to undertake a pro bono financial feasibility study of
replacing the hospital. This process assured both credibility and buy-in from the larger
community for acceptance of the ultimate recommendations.
HMA recommends that this independent panel be appointed by the end of 2004, with a report
anticipated by the end of 2005.
E. Potential Provider Partnerships for the Parkland System
It is clear that no matter how efficient Parkland is now or ultimately becomes, it will never be in
the position to meet all of the health and medical needs of low-income people in Dallas County.
Even its own projections for the replacement of its facilities are based on addressing only half of
the projected indigent population health service demand for the county over the next decade.
Across the country, public health and hospital systems are learning that they simply cannot do
it all and need to enter into partnerships with other providers who are willing to be defined
parts of a “virtual safety net” to care for the indigent population in a particular community.
Most of these private health care providers understand that, given the growing number of
patients without insurance, they will ultimately see more medically indigent patients at any
rate, whether through their Emergency Departments (EDs) or their clinics. It makes much more
sense to plan ahead in a rational way to build on each other’s strengths and weaknesses,
whether clinical or geographic, and to spread out the responsibility over the entire health
system.
Throughout the course of this study, HMA interviewed the CEOs and other senior staff of
private hospitals, community health centers, mental health agencies and other public health
agencies. There was unanimous interest in both embarking on new collaborations with the
Parkland system or expanding existing relationships. The following represents some, though
clearly not all, of the potential areas for partnership development.
Private Hospitals
Other than Children’s Medical Center described below, the key private hospitals that serve
significant numbers of Medicaid/SCHIP and uninsured patients in the Dallas area appear to be

institutions in the Baylor, Methodist and Texas Health Resource (THR) systems. For the most
part, Medical City Dallas and Zale-Lipshy don’t serve substantive numbers of Medicaid and
uninsured patients (although the other hospital operated by UTSW, St. Paul, does provide
Medicaid and uninsured care in both its inpatient units and its ED). Several conclusions can be
made about these hospitals. First, while the overall percentage of inpatient admissions hovers at
a bit less than 20 percent Medicaid/SCHIP and 6 percent uninsured/self-pay for these
hospitals, the percentages over the past three years have been inching up. Second, a significant
number of Medicaid patients (between 13-16 percent) and uninsured patients (between 23-36
percent) utilize the EDs at these private hospitals, often seeking care that they could receive in
non-emergent settings. Finally, these numbers appear to be relatively consistent and growing
across all institutions.
While private hospitals in Dallas are not in the same position as many private hospitals serving
inner city populations in other metropolitan areas (where it is not uncommon to have more than
a few private hospitals providing care to 50-70 percent Medicaid and uninsured), the trend is
clearly worrisome to these hospitals. The projected growth of the uninsured in Dallas and the
continuing low Medicaid reimbursement are certainly detrimental to the bottom lines of private
hospitals, institutions that operate with no direct subsidy for care provided to the indigent. The
continued stability of the Parkland system, including its COPC clinics that deflect some of the
ED volume from these private hospitals, is of paramount concern to the Dallas private hospital
industry. The willingness to look at expanded and formalized partnerships with Parkland to
rationalize services to the low-income population was endorsed by every CEO interviewed.
The key areas of potential collaboration to be explored should include, but not be limited to:
financial support, clinical collaboration, capital investment and political engagement. Several
private hospitals already provide support to specific Parkland COPCs. These commitments
should be solidified and expanded, based on the need in the communities jointly served by the
private hospital and the Parkland clinic. Support can include direct financial subsidy of clinic
operations, capital development (space), and access to clinical support services. (specialty and
diagnostic services for clinic patients).
Further, as Parkland moves toward a replacement of its current hospital, intensive discussions
should occur with private hospitals to determine opportunities for decentralizing some services,

through contract or joint venture, to better serve a geographically changing low-income

population. In addition, there are clinical service needs that are currently not being met at
Parkland that could pose on opportunity for collaboration with other hospitals. Most notably
partnerships in the development of specialty outpatient, rehabilitation and some tertiary
service capacity should be actively pursued. Evaluation of the best partnerships should include
economic realities as well as quality and responsiveness of services.
Finally, efforts to increase the availability of federal dollars matching the local government
contribution of Dallas County to the provision of health care services should be heavily
supported and, in some cases, led by the private sector hospitals and their business-oriented
Boards, whether or not they are directly benefited. It is clear that keeping Parkland a vital health
care institution is of enormous indirect benefit to these institutions and to the entire community.
Children’s Medical Center
An obvious partner to Parkland in the more formal creation of a health care system for the
indigent is Children’s Medical Center (CMC), located adjacent to Parkland hospital. In the mid-
1990s, a mutual agreement was reached between CMC and Parkland for CMC to take on the
responsibility of the pediatric patients, including the indigent, who previously had been cared
for at Parkland. The hospital is now disproportionately dependent upon Medicaid and SCHIP
and so, over the past few years, has been significantly impacted by the reductions in these
programs by the State of Texas
Parkland and CMC already interact on several different levels. The hospital provides the
inpatient, emergent and subspecialty outpatient back-up to the pediatric primary care delivered
at Parkland’s COPC clinics. Some of the COPC physicians, who are also UTSW faculty, rotate
on the inpatient units at CMC and supervise pediatric residents in the COPC clinics. It is
generally felt, by both COPC and CMC leadership, that this is a positive relationship that
should be expanded. The CMC has established its own neighborhood health center in a
community in which many patients who had been utilizing its ED reside and found that effort
to have a profound effect on reducing unnecessary ED visits. As the COPCs currently are
located in communities that make up the CMC ED primary service areas, the potential for
collaboration is significant.

New partnership areas of focus should include the following elements: 1) implementation of a
formal appointment process from the CMC ED to COPC clinics for patients seeking primary
care; 2) the exploration of co-location of CMC pediatricians into existing or new COPCs to
increase pediatric primary care capacity and further encourage the redirection of patients out of
the ED; and 3) collaboration on accessing specialty care outpatient visits for COPC children, a
growing problem as the eligibility for SCHIP in Texas has been constrained.
The partnership potential for the two institutions extends to joint facilities planning. Both
CMC and Parkland are in the midst of Master Planning efforts for new and/or expansion
facilities on the same campus. Discussions should be initiated to determine potential areas of
collaboration, whether in facilities or services. The leadership of CMC has clearly stated its
interest in being part of a coordinated approach to the care of low-income people in the County.
Veteran’s Administration/North Texas Region
In recent years, Veteran’s Administration (VA) hospitals have been given a great deal more
latitude in entering into partnerships with other non-VA health care providers. The VA in
Dallas, which serves over 40 counties in north Texas and Oklahoma, is a major health care
resource for the community, providing nearly 1 million primary and specialty ambulatory visits
every year to veterans in its catchment area, as well as significant inpatient, mental health and
long-term care capacity. There have been previous discussions about developing collaborative
initiatives between Parkland and the VA and some efforts have been made in that direction. The
two institutions share many of the same patient populations and collaboration could better
assure that resources are used most appropriately.
The VA is widely respected across the country for its efficiency and quality assurance in the
implementation of a pharmaceutical distribution system, particularly in the area of mail order
prescription refills. Recently, the North Texas VA has doubled its capacity for taking on
additional business and would be interested in collaborating with Parkland in more efficiently
providing refill medications for its patients. The VA has also developed formal contracts with a
network of longterm care providers that allows the VA to more efficiently discharge patients
out of its acute care institution. Many of their patients, as Parkland’s, have special needs that
have to be accommodated. The VA would be interested in assessing the potential for

collaborating with Parkland on this contracting effort. The VA also operates its own home
health service, made up of nurses and nutritionists and therapists and home health aides. This
service now provides care for several hundred VA patients in their homes, decreasing the
likelihood of unnecessary hospitalizations. They would be interested in exploring the potential
for extending that service to Parkland patients.
Despite the extensive ambulatory capacity currently operated by or contracted with the VA,
there is interest in exploring the potential with Parkland of contracting for primary care for
veterans at the COPCs that serve particular neighborhoods and communities. In addition, there
is interest in jointly assessing the opportunities for developing community-based mental health
services, both inpatient and outpatient. This is an area in which Parkland is currently
overwhelmed, particularly in inpatient psychiatric capacity, and the VA has committed to
expand services.
There appears to be a willingness to explore what seem to be significant partnership

opportunities between the Parkland and VA systems. A process should be commenced at the
highest levels to begin these discussions.
Community Primary Care
Despite the substantial primary care load provided by Parkland’s COPCs, there are only two
federally supported community health centers in Dallas County, Martin Luther King and Los
Barrios. This is substantially less subsidized primary care than exists in other large metropolitan
areas (Chicago, for example, has 25 community health centers with 90 sites). In an effort to
address this disparity, the Dallas County Medical Society has established a program called
Project Access and there are a number of free-clinics developed through faith-based groups and
social service programs to attempt to meet the growing need of the uninsured. Several
neighboring counties are also pursuing the development of primary care for the indigent.
There appears to be relatively little formalized joint planning and collaborative thinking about
where to locate facilities or how to resolve problems accessing services and pharmaceuticals for
the patients served by these clinics and programs. It would benefit Parkland to take the lead in
bringing these providers together to begin discussion about potential areas of coordination.

Further, the common issue for most of these primary care providers is access to specialty and
diagnostic services at Parkland for their indigent patients. Establishing a rational referral
process will serve to decrease the number of unnecessary admissions into the Parkland ED or
inappropriate specialty referrals from providers simply trying to get consultations for their
patients, while potentially easing the current backlogs.
Other Health Care Agencies
There are numerous other health care and social service agencies that could serve Parkland’s
patients with greater coordination. Parkland clearly has well-established and ongoing
relationships with many of these agencies but there may be the potential for increased
collaboration. Key priorities to explore for more effective partnerships would include the
County’s own public health department as well as that of the City of Dallas. The option for co-
locating public health services into COPCs should be explored to assess the potential for
minimizing duplication and enhancing the effectiveness of services for those patient
populations designated at risk by both the public health department and the COPCs. There is
also the potential for increased grant funding for programs that combine the efforts of public
health and medical providers to address the needs of vulnerable populations and communities.
Discussions should also be held with Dallas MetroCare Services, the quasi-public organization
that provides mental health care to approximately ¾ of the Medicaid and uninsured population
in Dallas County. While there may be some constraints in the definition of populations served
under this program, the need for enhanced mental health services by Parkland and a more
formal partner for medical services by MetroCare is clear. A partnership has been established
between MetroCare and the Parkland ED and seems to be successful. This model should be
built upon and expanded.
In order to assure the most effective and efficient use of the resources of the Parkland system,
other partnerships should be developed and formalized with nursing homes, home health
agencies, and substance abuse treatment centers. These partnerships should, whenever
possible, be developed by meeting each other’s needs, providing value to each other. Many of
these relationships already exist and the focus should be on building real systems of care for the
future.

F. Governance Effectiveness Issues for Dallas County, the Dallas County Hospital
District and the Parkland Health and Hospital System
Background
The conclusions that HMA has drawn related to the structure of governance over policy-
making and operations of the Parkland Health and Hospital System are based on extensive
interviews with all of the Commissioners of the Dallas County Court (the Court), the Members
of the Board of the Dallas County Hospital District (the Board), senior administrators of the
Parkland system and UTSW, and leadership from throughout the health care, business, civic
and advocacy sectors of the Dallas community. The analysis was also influenced by the
experience of other governance models of public hospital systems throughout the country,
which include direct governance by the elected County administration (Cook County, Los
Angeles County, San Francisco), separately incorporated public benefits corporation (New
York), municipal corporation (Marion County/Indianapolis), public health authority (Denver,
Boston), 501(c) (3) hospital (Memphis), to other models.
The primary findings on the issue of governance are as follows:
• the structure of governance utilized in Dallas is not, in and of itself, an impediment to

efficient operations of the delivery system;
• a dysfunctional situation has evolved over the past several years which has resulted in a
culture of distrust between the Court, the Board and Parkland administration;
• the Court has taken on some level of operational oversight (such as the approval of
contracts over $200,000) which would otherwise have been beyond its purview in part in
response to the lack of effective synergy between the Board and Parkland
administration;
• there has been vocal and public participation in the governance process by members of
the business, civic and advocacy communities; and
• the roles and responsibilities have become blurred and unclear between the Court and
the Board and those expectations need to be redefined.

HMA recommends the following areas of redefinition in order to assure competent, non-
duplicative, accountable and efficient governance of the Parkland Health and Hospital System.
The Role of the Dallas County Commissioners Court
The Court should reassume its role as the government body ultimately responsible for:
1) assuring maximum leveraging of County dollars to gain all available federal dollars,
minimizing the need to rely solely on the County taxpayers to assume the costs of the
uninsured and Medicaid patients not adequately funded by the State of Texas;
2) negotiating regional approaches to the financing and/or delivery of health care services
for the indigent;
3) approving the acquisition or disposition of property and the issuance of debt by the
Dallas County Hospital District;
4) approving the Dallas County Hospital District annual budget;
5) setting the tax rate; and
6) appointing the members of the Board of the Dallas County Hospital District.
In this latter role, the Court should consider a new appointment process to assure that Board
members have the skill and experience to provide effective oversight to a highly complex health
care system. In much the same way that local communities have formed groups to review
candidates for local judgeships (like the Committee for a Qualified Judiciary in Dallas), the
Commissioners Court would establish a “nominating committee” to review candidates for
members of the Board of the Dallas County Hospital District. This Committee would be
comprised of representatives from key business, civic and health care organizations and would
be charged with reviewing potential Board members based on a set of criteria for experience,
skills, Board composition and other factors determined by the Court. The Committee would
review resumes and interview all interested candidates and then present a list of “qualified”
potential Board members to the Court. The Court would then vote among themselves for the
seven people who would ultimately be named to the District Board.

This process would emphasize the critical need for highly skilled people to be Board members,
provide the Court some isolation and eliminate charges of politicizing the process, and involve
the broader interests of the community in selecting those who are responsible to assure that the
Parkland system is acting in the interests of the entirety of Dallas County.
The Role of the Dallas County Hospital District
The Board of the District needs to function in the same manner as any other Board of Trustees
of a large health care system. Its primary responsibilities and areas of focus should be:
• establishing system-wide policies related to the clinical, administrative and financial

performance of the Parkland system;
• assuring the development and adoption of strategic operational plans, with clear goals
and objectives, including plans for capital, partnerships with other providers, scope of
services and other aspects of assuring the most effective health system possible;
• reviewing and approving any issue (i.e., budget, land acquisition or disposition,
issuance of debt) ultimately requiring County action prior to presentation to the
Commissioner’s Court; and
• appointing the Parkland system CEO and holding him/her accountable for performance
objectives established on an annual basis and, in order to function most effectively, the
Board needs to rely on its CEO to provide information to and be accountable for the
performance of other senior staff.
Conclusion
The governance model for Dallas County health care services can actually provide
accountability and political strength if the roles for both the Court and the District--and the
administration of the Parkland system--are clearly delineated and if there is a shared
understanding of the institutional mission. It has been HMA’s experience during the course of
this project that there is a desire by the principals at all levels of the system to reach a standard
of trust and shared commitment to the maintenance of an effective health care delivery
operation and to the assurance of the health of the public of Dallas County.

CHAPTER 3: RECOMMENDATIONS FOR LONG-RANGE PLANNING

PRIORITIES FOR THE DALLAS COUNTY HOSPITAL
DISTRICT
The recommendations that follow are discussed in detail in Chapter 2 and additional
documentation is also available in the Appendices of this report. It should be noted that these
recommendations do not represent all of the areas that HMA has identified for further activity
but, rather, constitute those priorities for long range planning attention by the Dallas County
Commissioners Court, the Dallas County Hospital District and Parkland administration.
Financial impact is given whenever a degree of certainty is available.
Priorities for Parkland System Clinical Operations
System-Wide Issues
1) Make the recruitment of a Chief Operating Officer for the Parkland system a priority
and ensure that there is a more integrated approach to planning and operations for the
system as a whole, avoiding “silos” of management within the system.
2) Begin, in partnership with the University of Texas Southwestern (UTSW), a process to

reassess policies and procedures and allocation of clinical resources that were developed
to facilitate teaching in Parkland but now may inhibit effective operation of the health
system.
3) Establish an agenda of operational issues to be addressed to maintain current paying

patients in the Parkland system, particularly Medicare patients, to increase revenue to be
used to off-set the cost of the growing number of uninsured.
4) Initiate serious and specific discussions with other health care providers to identify areas
of potential collaboration.

Primary Care
5) Make the improvement of access to the COPC clinics as a primary focus of the Parkland
system, addressing such issues as the ease of appointment scheduling (working with the
Parkland and Children’s EDs, specialty clinics and inpatient services), hours of
operation, the cash collection and financial screening policies that may result in
disincentives to utilize the clinics and send people to more expensive EDs, and provider
productivity efforts to assure the maximum utilization of capacity.
6) Better integrate the health services delivered at the COPCs with the needs of the
communities that are served by: coordinating with the medical, public health and
mental health services offered by other agencies; assessing the potential for expansion or
contraction of clinics based on population growth or movement; and maintaining the
ongoing role of community advisory boards in assuring that the services offered at the
COPCs are meeting the specific needs of the communities that they serve.
7) Ensure that the COPCs are seen as an essential component of the continuum of care by
the entire Parkland system, including the clinical leadership. Issues of referrals,
admission procedures, policies, medical staff communication and resource allocation for
the COPCs must be viewed for their impact on every aspect of the Parkland system.
Specialty Care
8) Initiate an immediate and thorough assessment of the clinical resources and space
needed to provide accessible specialty outpatient services for the patients who depend
upon the Parkland system for that care who otherwise will inappropriately utilize the
Parkland ED or be admitted for services that could have been provided in specialty
clinics.
9) Develop a plan to reallocate or, where necessary, expand resources dedicated to certain
specialty areas where there is a current deficit.
10) Develop a referral system, based on sound clinical guidelines, that will assure ease of
access to specialty services, the appropriateness of referrals to specialty care, and return
to primary care after the specialty consult to avoid misuse of scarce resources.

11) Explore the potential for partnering with other hospitals and/or physician groups to
expand accessibility to specialty outpatient services, particularly in less expensive and
more accessible community-based settings.
Emergency Services
12) Initiate a major overhaul of the Parkland admissions processes, addressing such issues
that are contributing to the current backlog as: the resident-driven “AOD” system, the
policy of requiring diagnostic work-ups before patients leave the ED, and the inability of
other parts of the system (COPCs, specialty clinics) to directly admit patients into the
hospital.
13) Develop an effective referral system to allow ED physicians to send patients needing
ongoing care to COPC or specialty clinics.
14) Explore the potential for establishing Observation Bed capacity adjacent to the ED to
minimize unnecessary admissions into the hospital.
15) Begin a review of clinical policies that may adversely impact efforts to prevent
unnecessary return visits to the ED (i.e., asthma) and/or may assist in efforts to develop
system-wide disease management protocols.
Inpatient Care
16) Establish bed control as an institutional priority, building on recommendations from

previous consultant reports and involving clinical as well as administrative leadership.
17) Rationalize the current logjam in the operating rooms by reassessing the management
structure (including reassigning case managers who had been replaced by residents),
moving forward on the construction of the Ambulatory Surgery Center, and exploring
the potential for an interim strategy for moving outpatient surgeries into a temporary
location at another institution.
18) Initiate a process, with clinical leadership in OB/Gyne, to restructure the inpatient units
assigned to Labor and Delivery to assure the most effective utilization of all inpatient

beds while, at the same time, maintaining the protocols that have resulted in such
impressive outcomes.
19) Investigate the potential for immediate conversion of unused space within Parkland to
expand the capacity for rehabilitation services at Parkland, allowing for the retention of
current paying patients who are now being sent to other institutions.
Gaps in the Current System
20) Develop a comprehensive plan, perhaps in connection with the VA or other providers,
for access to long-term care for Parkland patients. While the areas of mental health,
substance abuse and home health care services also need to be addressed, immediate
priority should be given to the establishment of a vehicle for Parkland to more easily
discharge patients into less costly nursing home beds. This part of the continuum of care
will become increasingly important as the population continues to age and as the issue
of the bed need for a replacement for Parkland Hospital is discussed.
Disease Management
21) Implement a disease management approach throughout the Parkland system, targeting
those chronic conditions (i.e., diabetes, asthma, hypertension) that have the greatest
impact on Parkland resources and its patients. This approach has been proven to save
money and improve health outcomes and will require the cooperation of the medical
and administrative leadership (primary, specialty, emergent, inpatient), the involvement
of information systems and quality assurance personnel and the designation of clearly
identified accountability and authority within the system.
Medical Staff Relationship
22) Resolve the current FY2005 faculty contract between Parkland and UTSW and view it as
a transition agreement, beginning immediately to negotiate the contract for FY2006
based on covering appropriate costs, verifiability, and adequate payment for all clinical
service expansions.

23) Begin to develop a new Master Affiliation Agreement between the two institutions that
will reconfirm the importance of the relationship and will address, at minimum:
• job descriptions and the search process for new, dedicated medical staff
leadership for Parkland, with clear authority/accountability at both the
hospital and UTSW;
• the process for annual assessment and negotiation of costs for the faculty
contract;
• operational areas of concern at Parkland related to the inherent tension

between academic facilitation and clinical efficiency (i.e., admission policies,
discharge procedures, specialty care allocation and connections);
• the responsibility of Parkland to assure an agreed upon level of operational

and administrative support to clinical services; and
• the process for collaboration related to the long-term planning efforts of both
Parkland and UTSW and procedures for resolving potential areas of conflict).
Physical Plant Issues
24) Initiate discussion now between Parkland and the Dallas County Hospital District about
the development of a Master Capital Plan for the Parkland system.
25) Determine capital project priorities for the current system that will either assure greater
efficiency or allow for the generation of increased revenue. Priority areas should include
the construction of the Irving COPC and the Ambulatory Surgery Center, and the
renovation of existing space for the establishment of increased rehabilitation capacity
and observation beds adjacent to the ED.
26) Establish a “blue ribbon panel,” appointed by the Dallas County Court of
Commissioners and the Dallas County Hospital District, made up of key health care,
civic and business leaders. This panel would be charged with overseeing the
development, with Parkland leadership, of a Master Capital Plan for the system,
including the scope of and financing for a facilities replacement strategy for Parkland
hospital.

Priorities for Health Care Financing
System Financial Strategies
1) Leverage available Dallas County funds through a variety of special financing

mechanisms, including the following. It is important to note that the leadership of the
Court and the support of the local business community will be critical to garnering State
support for these efforts.
• Take advantage of additional Upper Payment Limit (UPL) payments by

increasing Parkland’s charge structure. (Estimated impact = $ 16 million
currently, although further data analysis may lower that figure)
• Secure a federal waiver for Medicaid to cover the costs of prenatal care for
undocumented immigrants. (Estimated impact = $5 to $7 million)
• Increase Medicaid payments to Parkland and UTSW physicians.
• Secure increased Medicaid managed care rates through risk adjustment and/or
increasing the base rate on which the managed care rates are set. (Estimated
impact = $5.6 million)
• Utilize the Upper Payment Limit (UPL) capacity of other private hospitals in
Dallas County that serve large numbers of Medicaid and uninsured patients.
(Estimated potential= $225 million; $105 million if Children’s is excluded)
2) Explore the creation of a 501 (c) (3) charity care entity to help fund care at Parkland and
other organizations in the community.
3) Work with the counties contiguous to Dallas and the State to establish a regional trauma
network that would help finance trauma care provided by Parkland to out-of-county
patients by leveraging current County Indigent Health Care Program (CIHCP)
expenditures. (Estimated impact = $10 million)
4) Convert Parkland’s COPC clinics to Federally Qualified Health Centers (FQHCs).

(Estimated impact = $9.3 million)

5) Carefully evaluate new service opportunities for their potential to be successful given
Parkland’s demographics and payor mix. These include rehabilitation, long-term care
and psychiatry.
Financial Management
6) Ensure that Parkland has a long-term strategic business plan in place that reflects the
collective input of the operational, financial and medical leadership. The strategic plan
should be supported by a long-range capital plan and an information technology (IT)
plan. All of these documents are needed to help the Board make decisions based on the
best available information and the long-range goals of the organization.
7) Begin work immediately on negotiating the 2006 contract with UTSW to produce an
easy-to-understand, transparent, and verifiable agreement in a timeframe that allows it to
be incorporated into the budget process.
8) Continue to build on revenue cycle improvements by increasing conversion of patients

to funded sources, improving time-of-service collections and implementing a stronger
denial management and collections strategy. (Estimated impact = $6 to $8 million).
9) Begin to consider the mutual benefits of a combined revenue management entity that
combines the hospital and the medical school revenue management processes, including
medical records, billing and collections.
10) Improve the position of the Parkland Community Health Plan by reducing
administrative costs to the industry standard, reducing payment rates to the Medicaid
rate, and reducing payments for non-participating providers. (Estimated impact = $8.2
million)
11) Ensure that Parkland is positioned to take advantage of pharmacy opportunities

afforded by the Medicare Modernization Act (MMA), including the discount card
program, low-income subsidies, and mail order, potentially through a partnership with
the VA Hospital. (Estimated impact = up to $11.7 million, not including mail order).

Priorities For Partnership Development and Expansion
1) Initiate discussions with the leadership of private hospitals in the Dallas community to
determine the potential areas of collaboration for current and future health services
provided for low-income residents of the County including, but certainly not limited to:
support (financial or service) for existing or expanded COPCs, collaboration on the
provision of community-based specialty outpatient services, joint development of
service lines (i.e., rehabilitation services), and the delivery of tertiary services for
Parkland patients. These partnerships should be approached as an opportunity to
provide a mutually beneficial vehicle to minimize duplication and spread responsibility
for meeting needs of indigent patients more equitably.
2) Develop expanded collaboration with Children’s Medical Center, particularly focusing

on: enhancing access into the COPC clinics for patients coming to the Children’s ED for
primary care; collaborating on expanded community-based pediatric specialty care
access; exploring the potential of co-locating Children’s physicians in COPC facilities;
and better coordinating facilities and support service planning on the medical center
campus.
3) Enter into serious discussions with the Veteran’s Administration Hospital system in
Dallas to explore potential partnerships in such areas as: participating in the VA’s mail
order pharmaceutical program, one of the most effective in the country; connecting to
the VA-affiliated network of nursing home providers and contracting with its home
health services, both efforts to assure that patients do not stay in inpatient beds
unnecessarily; entering into an agreement whereby the VA would contract with the
COPCs for primary care for its veterans; and planning for a collaborative approach to
mental health services.
Priorities for an Effective Health System Governance
1) Ensure that the roles and responsibilities of the Dallas County Commissioners Court and
the Dallas County Hospital District be clearly defined and duplication should be
eliminated whenever possible.

2) Empower the Dallas County Commissioners Court to appoint a civic “nominating

committee,” made up of health care, business, civic and community leaders, to screen
potential candidates for the Dallas County Hospital District for skills and expertise
outlined in a clear job description for Board membership. This committee would present
a slate of a number of candidates that they have deemed to be “qualified” from which
the Court would select the Board’s membership. This process would go far in assuring
that the members of the District Board were committed, skilled and as unaffected as
possible by political pressure, real or perceived.

APPENDICES
A. Project Interview/Interaction Listing
B. Maps
C. Private Hospital Data Profiles
D. Project Access, FQHCs, Free Clinics, and Public Health Departments
E. Parkland Health & Hospital System, Uncompensated & Undocumented Health Care
Analysis (Economic Projections)
F. Medicaid Reimbursement Comparisons
G. Pharmacy Issue Paper
H. Parkland Community Health Plan Report
I. Finance Deliverables
J. Revenue Cycle Report
K. COPC Assessment Report
K-1. COPC Assessment
K-2. COPC Maps
K-3. Community Clinic Profiles
K-4. Operations Plan performance
COPC Service Standards
Financial Management Tool
Care Team Roles
K-5. COPC Staffing Tool June 2004
MGMA 2002 Benchmarks
K-6. EPIC Newborn Appointments COPC

Project Interview/Interaction Listing
Chad Adams Paul M. Bass

Judge Chairman of the Board
Ellis County Southwestern Medical Foundation;
Vice Chairman
Kevin Alaggio First Southwest Company
Associate Director of Nursing
Parkland Health & Hospital System - Katrina Bassel, M.D.
COPC Board Member
Dallas County Medical Society
Joel Allison
President & CEO John Baumgartner
Baylor Healthcare System Senior Vice President
Methodist Health System
Rita Alvarez
Member Bruce Beaty
COPC Advisory Board Commissioner
Rockwell County
Ron J. Anderson, M.D.
President & CEO Louis A. Beecherl, III
Parkland Health & Hospital System Board Member
Myra Austin
Christ’s Family Clinic Syl Benenson
Member
Arturo E. Aviles, M.D. COPC Advisory Board
Board Member
Dallas County Medical Society Mary Bergman, M.D.
Lead Physician (Pediatrics)
Tim Bahe Parkland Health & Hospital System -
President & CEO COPC
Parkland Community Health Plan
Britt Berrett
James G. Baker, M.D. President & CEO
CEO Medical City Hospital
Dallas Metrocare MHMR Services
Deaina Berry, M.D.
Claudia Barner Lead Physician (Pediatrics)
Dallas Area Interfaith (Wilshire Baptist Parkland Health & Hospital System -
Church) COPC
Pam Barnes Bill Bilyeu

Director of Reimbursement County Administrator
Baylor Healthcare System Collin County
Health Management Associates Appendix A

Jan Hart Black Ryan Brown
President Chief Financial Officer
Greater Dallas Chamber of Commerce Dallas County
Member
Dallas Medical Resource Bing Burton
Director of Public Health
Martha Blaine Denton County
Board Member
Community Council of Greater Dallas Craig Callewart, M.D.
Board Member
Jim Blasingame Dallas County Medical Society
Finance Department
Parkland Health & Hospital System Linda Camin
Member
Steve Bloom, M.D. League of Women Voters
Associate Chief of OB Service
Parkland/UTSW Mike Cantrell
Commissioner
Charlene Bonvissuto Dallas County
Project Manager, Parkland Project
Capgemini Sister Pearl Ceasar
Dallas Area Interfaith
Paul Boumbulian
Former Stategic Planning Director Lynn Cearley
Parkland Health & Hospital System Dallas Area Interfaith
Dorruth Boyd Denise Chamberlain

Coordinator Vice President of Finance
Head Start of Greater Dallas Parkland Health & Hospital System
Susan Briner, M.D. Howard Chase

Lead Physician (Pediatrics) President & CEO
Parkland Health & Hospital System - Methodist Health System
COPC
Juanita Chism
Adeline Brown Lead Nurse (Geriatrics)
Member Parkland Health & Hospital System -
Texas Silver-Haired League COPC
Rick Brown Gretchen Claiborne

Sr. Vice President Associated Director
(Facilities/Master Plan) Texas Council of MHMR Centers
Parkland Health & Hospital System
Patti Clapp
Member
Greater Dallas Chamber of Commerce

Allen Clemson Michael Darrouzet
Chief Operating Officer CEO
Dallas County Dallas County Medical Society
Reed Click, M.D. Joe DaSilva

Attending Physician, Internal Medicine Sr. Vice President (Advocacy &
Parkland/UTSW Education)
Texas Hospital Association
Phyllis Cole
Commissioner Sharon Davis, M.D.
Collin County Lead Physician (Family Practice)
Parkland Health & Hospital System -
Jennifer Coleman COPC
Sr. Vice President (Public Affairs)
Baylor Health Care System Albert de la Cruz
Vice President (Business Services)
Sheila Coleman Parkland Health & Hospital System
Lead Nurse (Pediatrics)
Parkland Health & Hospital System - Kay Dial
COPC Clinic Coordinator
Agape Clinic
Theresa Comstock
Dallas Area Interfaith Maurine Dickey
(Transfiguration Episcopal Church) Former Chairperson
Dia Copeland
Site Administrator Keri Disney
Parkland Health & Hospital System - Director of Government Reimbursement
COPC Parkland Health & Hospital System
Suzanne Corrigan, M.D. Christopher Durovich

Board Member President & CEO
Dallas County Medical Society Children's Medical Center
Vicki Crane Bruce Fairbanks

Vice President (Pharmaceutical Vice President (Financial Affairs)
Services) UT Southwestern Medical School
Gretchen Feinhals
Jennifer Cutrer Member
Director, Legislative Affairs COPC Advisory Board
Mike Fichtel
Vice President/CFO
Children's Medical Center

Argentry Fields John Gavras
Site Administrator President & CEO
Parkland Health & Hospital System - Dallas Fort Worth Hospital Council
COPC
Wayne Gent
Greg Fitz, M.D. County Judge
Chairman of Internal Medicine Kaufman County
Parkland/UTSW
Artie Giles
April Foran Member
Corporate Communication COPC Advisory Board
Gary Godsey
Charlotte Forswall President & CEO
Finance Department United Way of Metropolitan Dallas
Mary Greene
Veletta Forsythe Lill KERA
Dallas City Councilwoman
Dallas County Charles L. Gummer
Board Member
Dan Foster, M.D. Dallas Medical Resource (Comerica
Former Chairman of Internal Medicine Bank)
Parkland/UTSW
Robert Haley, M.D.
Annie Franklin Past President
Sr. Vice President (Medicine Services) Dallas County Medical Society
L.W. Hall
Silvia Gallegos Senior Citizens Council
Member
COPC Advisory Board Donna Halstead
President
Gilbert Galvan Dallas Citizens Council
Program Specialist V
Health & Human Services Commission L. Levet Hamilton
Lead Nurse (Pediatrics/Adult)
Trini Garza Parkland Health & Hospital System -
Executive Director COPC
La Voz Del Anciano
Shirlisa Hampton
John Gates Associate Director of Business Services
CFO Parkland Health & Hospital System -
Parkland Health & Hospital System COPC

Kathy Hanold Maria L. Hernandez
Sr. Vice President, WISH (Womens & Policy Analyst
Infants) Dallas County
Paul Hoffman
Walker Harman Executive Director
Chairman of the Board Dental Health Programs of Dallas
Baylor Health Care System
Bert Holmes
Alan Harper Chairman
President & CEO Senior Citizens Board
VA North Texas Health Care System
Janice Holmes
John Harris WISH
Member Parkland Health & Hospital System
COPC Advisory Board
Cindy Hogan
Adlene Harrison Director of Corporate Affairs
Former Mayor Texas Health Resources
Dallas County
Mary Horn
Cathy Harrison Judge
Lead Nurse (Adult/Geriatrics) Denton County
COPC Jane Hunley
Director (Geriatrics)
Douglas Hawthorne Parkland Health & Hospital System -
President & CEO COPC
Texas Health Resources
Ray L. Hunt
Jim Hayman Chairman of the Board
Sr. Vice President Dallas Medical Resource (Hunt
(Pharmacy/Purchasing/Laboratory) Consolidated)
Emmanuel Inyang, M.D.
Barry Henry Lead Physician (Adult/Geriatrics)
Managing Director Parkland Health & Hospital System -
Crow Holdings COPC
Jessica Hernandez Laura Irvine

Site Administator Senior Vice President (Planning &
Parkland Health & Hospital System – Marketing)
COPC Methodist Health System

Jim Jackson James Kennedy, M.D.
Commissioner Lead Physician (Pediatrics)
Dallas County Parkland Health & Hospital System -
COPC
Lee Jackson
Chancellor Rehan Khan, M.D.
University of North Texas System Lead Physician (Internal Medicine)
Claudie Jimenz, M.D., M.S. COPC
Assistant Professor
UT Southwestern Medical Center Renuka Khurana, M.D.
Lead Physician (Pediatrics)
Reverend Peter Johnson Parkland Health & Hospital System -
Dallas NAACP COPC
Jim Johnson Kirk Kirksey

Manager (Benefits & Compensation) Vice President (Information Resources)
Parkland Health & Hospital System UT Southwestern
Denise Johnson, M.D. Harold Kleinman

Lead Physician (Family Practice) Chairman of the Board
Parkland Health & Hospital System - Methodist Health System
COPC
J. Peter Kline
Larry Jones Board Member
Commissioner Dallas Medical Resource (Seneca
Ellis County Advisors)
Walter Jones Richard Kneipper

Facilities Planning & Development Board Member
Parkland Health & Hospital System Dallas County Hospital District
Margaret Jordan John Knutson

Executive Director Dallas Area Interfaith
Dallas Medical Resource;
Executive Vice President Mike Korpiel
Texas Health Resources Sr. Vice President (Surgical Services)
Bethanne Keating
Parkland Health Plus Jack Kowitt
Senior Vice President & CIO
Margaret Keliher Parkland Health & Hospital System
Judge
Dallas County Commissioners Court Pauline Kress
Friends of Senior Affairs of Dallas

LeAnn Kridelbaugh, M.D. Ann E. Margolin
Lead Physician (Pediatrics) Former Chairperson
Parkland Health & Hospital System - Dallas County Hospital District
COPC
Adriane Mahnken
Barry Lachman, M.D. Associate Director
Medical Director Managed Care Contracts
Parkland Community Health Plan
Mary E. Mancini, PhD, RN, CNA,
Charlene Lawrence FAAN
Clinic Director Former Chief Nursing Officer
Dallas Life Foundation Parkland Health & Hospital System
Jonathan Leffert, M.D. Glenna Maples

Board Member Director of Planning & Business
Dallas County Medical Society Development
Texas Health Resources
Kenneth Leveno, M.D.
Chief of Service/OB/GYN Leonor Márquez
Parkland/UTSW Site Administrator
Warren Lichliter, M.D. COPC
President
Dallas County Medical Society Kenneth Mayfield
Commissioner
Amy Lindley Dallas County
Director of the Senate Committee on
Health & Human Services Susan McBride
Vice President (Data Initiative)
Dalton Lott Dallas Fort Worth Hospital Council
Board Member
Dallas County Hospital District John McConnell, M.D.
CEO
Ted Lyons University Medical Center, Inc.
Product Manager
Parkland Community Health Plan Pam McDonald
Health & Human Services Commission
Willis Maddrey, M.D.
Sr. Vice President (Clinical Affairs) Lauren McDonald, M.D.
UT Southwestern Medical Center Chairman
G.K. Maenius
Administrator Darren McGuire, M.D.
Tarrant County Assistant Professor of Internal Medicine
Parkland/UTSW

Nina McIntosh Bob Parkey, M.D.
Vice President (Ambulatory Services) Chairman of Radiology
Parkland Health & Hospital System Parkland/UTSW
Pam McNutt Tim Parris

Senior Vice President & CIO President & CEO
Methodist Health System Baylor University Medical Center
Joe Minei, M.D. Tena Patterson, M.D.

Chief of Trauma Lead Physician (Family Practice)
Parkland/UTSW Parkland Health & Hospital System -
COPC
Patsy Mitchell
Manager, Community & Public Health Lisa Payne
Dallas County Lead Nurse (Pediatrics)
Presley Mock, M.D. COPC
Board Member
Dallas County Medical Society Pam Peiffer
Assistant Vice President
Norman Moorehead UT Southwestern Health Systems
Director
Dallas Area Agency on Aging Patricia Peiser
Community Council of Greater Dallas Temple Emanue
Joseph Murphy, M.D. Paul E. Pepe, M.D.

Associate Professor of Surgery Chair of Emergency Medicine
Parkland/UTSW Parkland/UTSW
Muhammad Nasir, M.D. Donna Persaud, M.D.

Lead Physician (Internal Medicine) Lead Physician (Pediatrics)
Parkland Health & Hospital System - Parkland Health & Hospital System –
COPC COPC
LaVone Neal Rick Peters, Sr. Partner

Vice President (Decision Support) Health Data Partners, LLP
Baylor Healthcare System
Debbie Phillips, Sr. Partner
James Oesterreicher Lead Nurse (Pediatrics/Adult/Geriatrics)
Chairman of the Board Parkland Health & Hospital System -
Texas Health Resources COPC
Dighton Packard, M.D. Frank Phillips

Chief of Emergency Services Director of Administration
Baylor University Medical Center Denton County

Sharon Phillips John Roan, M.D.
Vice President (Operations) Executive Vice President (Business
Parkland Health & Hospital System - Affairs)
COPC UT Southwestern Medical Center
Sue Pickens Hortencia Rodriguez

Director, Strategic Planning Executive Director
Parkland Health & Hospital System Grand Prairie Wellness Center
Carolyn Pratt Robert D. Rogers

Health & Human Services Commission Board Member
Dallas Medical Resource (Texas
John Wiley Price Industries)
Commissioner
Dallas County Sharon Roland
Member, COPC Advisory Board
Joel Pugh
Jack Roper
Craig Purdue Senior Vice President (Finance)
Director of Gov. Relations Texas Health Resources
Dallas County
Samuel Ross, M.D.
Angelique Ramirez, M.D. Interim COO/CMO
Medical Director Parkland Health & Hospital System
COPC
Marcene Royster
Jaime Ramon Director of Community Services
Treasurer Parkland Health & Hospital System -
United Way of Metropolitan Dallas; COPC
Scott Reasonover Duke Samson, M.D.

Health & Human Services Commission Chairman of Neurosurgery
Parkland/UTSW
Bob Rege, M.D.
Chairman of Surgery Noel Santini, M.D.
Parkland/UTSW Lead Physician (Internal Medicine)
Doreen Reynolds COPC
Director of OR
Parkland Health & Hospital System Horace Sarabia
Executive Director
Yesenia Reyes Los Barrios Unidos Community Clinic
White Rock United Methodist Church

Joseph Schaffer, M.D. Susan Spalding, M.D.
Dept. of OB/Gyn Lead Physician (Pediatrics)
Parkland/UTSW Parkland Health & Hospital System -
COPC
Richard Schirmer
Texas Hospital Association Ronald G. Steinhart
Board Member
Leslie Secrest, M.D. Dallas Medical Resource (Bank One)
President-Elect
Dallas County Medical Society Jacqui Stephens
Director of Behavioral Health
Allan N. Shulkin, M.D. Parkland Health & Hospital System –
Board Member COPC
Andy Stern
Kathy Shumaker Chairman of the Board
Medical City Dallas Hospital Medical City Dallas Hospital
Member
Mike Sims Dallas Medical Resource
Temple Emmanuel
William L. Storms
Danica Simmons Member
Mission East Dallas COPC Advisory Board
Sandy Skelton Sandy Stuart

CEO Dallas Area Interfaith (King of Glory
Texas Council of MHMR Centers Lutheran Church)
Michelle Smith, M.D. Steve Svadlenak, Interim

Clinic Physician Executive Director
Central Dallas Ministries Texas Association of Public & Non-
Profit Hospitals
Trish Smith
Associate Vice President (Health System Lisa Swanson, M.D.
Planning) Board Member
University Medical Center, Inc. Dallas County Medical Society
William T. Solomon David J. Tesmer

Board Member Vice President (Government &
Dallas Medical Resource (Austin Community Affairs)
Industries) Texas Health Resources
Joel Sontag Zachary Thompson

Interim President Director
Oak Cliff Chamber of Commerce Dallas County Department of Health and
Human Services

Beverly Tobian William J. Walton, M.D.
Health & Human Services Coalition Board Member
Dallas County Medical Society
Lee Vaness
Assistant District Attorney Elgin Ware, M.D.
Denton County Medical Director
Stew Pot Medical Clinic
Kim Vernon, M.D.
Secretary/Treasurer John L. Ware
Dallas County Medical Society Board Member
Dallas Medical Resource (21st Century
Belinda Vicioso, M.D. Group)
Lead Physician (Geriatrics)
Parkland Health & Hospital System - Karen Ware
COPC Member
COPC Advisory Board
Joseph Viroslav, M.D.
Board Member Barbara Watkins
Dallas County Medical Society President & CEO
Parkland Foundation
Nancy Volk
North Dallas Shared Ministries Kerrie Watterson
Site Administrator
Fran Wagnon Parkland Health & Hospital System -
Member COPC
COPC Advisory Board
Connie Webster, M.D.
Michael P. Wainscott, M.D. Board Member
Professor Dallas County Medical Society
UT Southwestern Medical Center
Polly Weidenkopf
Eric Walker Member
Site Administrator COPC Advisory Board
Parkland Health & Hospital System –
COPC Henry Welles
Health & Human Services Commission
Thomas Wallace, M.D.
Senior Medical Resident George Wendel, M.D.
Parkland Health& Hospital System Dept. of OB/Gyn
Parkland/UTSW
Alan Walne
Board Member Colette White
Dallas County Hospital District Operations/Finance Manager
Parkland Health & Hospital System –
COPC

Martin White, M.D. David Young
Dallas Area Interfaith Former Executive Director
Dallas Area NorthStar Authority
Shelia White-Jackson, M.D.
Lead Physician (Adolescent) Lori Zamora
Parkland Health & Hospital System - Lead Nurse (Adolescents)
COPC Parkland Health & Hospital System -
COPC
Kern Wildenthal, M.D.
President
UTSouthwestern Medical Center
J. McDonald Williams
Board Member
Dallas Medical Resource (Trammell
Crow)
Jenny Williams
Mission East Dallas County Health
Ministries
Lee Williams
Member
COPC Advisory Board
Maggie Willis
Member
COPC Avisory Board
Harold Wilson
Member
COPC Advisory Board
Jerry Wimpee
Commissioner
Rockwell County
Gary B. Wood, Ph.D.

Board Member
Donnie Woodkins
Member
COPC Advisory Board

Dallas County Hospitals & COPC Clinics
Î
Í
Ì
35E
Ì
Î
Í
635 Ù
Ú
75
Baylor - Irving Coppell Baylor - Garland

RHD Memorial $
$ $ $$ Lake Pointe
$ Vista
$Las Med City $
Colinas Garland
Presbyterian
$
$
Vickery Ì
Î
Í
635
HealthSouth Zale
Baylor - Irving $
$ $ Doctors Ì
Î
Í
30
PPCC/FMC
$$
St. Paul $$
$ Mary Shiels Mesquite Community$
$ $
Parkland Scott Rite East
$$
$ Baylor U.
Children's
$
Baylor Heart Mesquite
$
Î
Í
Ì
30
deHaro $
Methodist
Ú
Ù
80
Ù
Ú
175
$
Southeast
$
$ ?
Bluitt-Flowers
Oak West
Ì
Î
Í
20
Ì
Î
Í
35E
Methodist Charlton$
Ù
Ú
67
$ COPC Clinic
Lancaster
$ Hospital
$ Í
Î
Ì
45
Heath Management Associates Appendix B

Medicaid Primary Care Providers by Service Area
High No. of Providers 300-400

Medium No. of Providers 200-250 Northern Corridor
Low No. of Providers 50-150 Mesquite/
Extra Low No. of Providers 0-15 Garland/
Vickery Rowlett
Stemmons
Irving Corridor
East
Dallas
West Dallas
Grand South
Prairie Dallas
South Oak Southeast

Northwest Cliff Dallas
Oak Cliff

COPC Locations & Distribution of Persons Under
200% of Poverty
Each blue dot equals 500 persons under 200% of poverty
$$ $$ $ $
Ì
Î
Í
35E
$$
$ $ $ $ $ $ $ $$
$
$ $ $$ $ $ $$ $$ $ $ $ $ $ $
$ $$ $
$ $$$ $ $ $ $$ $ $$$ $$
$ $$$$ $
$ $ $
$
$ $ $$ $ $ $$$ $$$ $ $ $
$
$ $
$ $ $$ $ $ $ $
$ $ $ $ $$ $
$ $ $
$$ $$ $$$$ $$ $$$$ $ $
$
$ $ $ $ $ $$ $ $ $$
$ $ $ $ $
$ $ $ $ $
$$ $ $$ $ $ Garland
$
$$ $ $$$ $
$ $ $ $
$ $ $ $$ $
$
$$ $ $ $ $$ $ $ $ $ $ $ $ $
$ $$ $ $ $ $$ $$$
$
$$ $ $$ $ $
$ $$ $ $ $$$75 $ $$
$ $ $$ $$
$ $$
$ $ $ $$
Ú
Ù$ $$
$ $$ $
$$ $$
$ $ $
$ $ $
$ $ $ $
$ $ $ $ $ $ $$ $$
$$$ $ $$ $ $ Vickery $$ $$$$
$$$ $$$
$ $ $ $ $
$$$ $$
$ $$ $$ $ $ $ $
$ $ $$$ $$ $ $ $ $$
$ $ $
$ $ $$$ $ $ $ $ $ $
$ $$$$ $ $ $ $
$$$
$ $ $ $ $
$ $$
$ $ $$$ $
$ $ $ $ $$
$$ $
$ $$ $ $ $ $$ $ $ $$
$
$ $ $ $$ $
$$ $$$ $ $$$ $ $$
$
$ $
$ $ $
$$$$ $ $$ $$ $ $$$ $ $ $
$ $ $
$ $
$ $$
$ $ $ $$ $ $ $ $$ $ $ $ $
$$ $ $ $$ $ $
$ $ $$
$ $$ $$ $ $ $ $ $ $$ $ $
$ $$ $ $ $ $ $$$ $ $$ $ $ $ $ $ $ $$$ $$ $
$ $
$ $ $ $ $$
$ $
$$
PPCC/FMC $ $
$ $ $$ $ $
$
$ $$
$$ $ $$
$$$ $$ $$ $
$ $ $ $ $$ $
$ $ $ $ $ $ $$ $
$ $ $$ $ $
$$$ $$ $ $$$ $$ $ $ $ $
$ $ $ $ $
$$ $ $$ $
$
$$
$
$
$ $ $ $
$ $$ $ $$ $$ $$$$$$ $$$
$$$ $ $$ $ $
$
$ $ $$ $ $
$
$$ $ $ $
$ $ $ $$ $
$
$ $ $
$ $
$ $ $$ $ $$ $ $$
East $ $ $ $ $$$ $$
$$
$$$ $ $$ $ $
$$ $ $$$ $ $ $$$ $ $$
$ $$ $ $ $ $ $ $$ $ $ $ $ $$ $ $$ $
$
$ $
$
$ $ $
$ $ $ $ $
$
$ $
$ $$ $ $ Ú
Ù 80
$
$ $ $ $ $ $ $ $$ $ $ $ $$ $
$ $ $$ $ $$ $ $
$$ $$ $ $$ $ $ $$ $ $ $$
$ $ $$ $ $$ $ $ $ $ $ $$$ $$
$ $ $$ $ $$ $ $ $ $$ $ $ $ $ $
$ $ $ $$ $ $ $ $
$ $$ $ $ $ $$ $ $ $$ $$ $
$$$
$ Î
Í
Ì30
$ $deHaro$ $$ $
$$ $$ $ $ $ $
$ $$$ $
$ $ $ $
$$$
$$ $ $ $ $ $$
$
$$ $ $
$ $ $ $
$
$
$$ $ $ $ $ $$$ $ $ $ $ $ $ $$ $ $$
$ $ Ú
Ù 80
$$ $ $ $$
$$ $
$$ $ $ $$$ $
$$ $$$ $$ $ $ $
$ $
$ $
$ $$
$$ $ $
$ $ $$
$
$ $ $ $
$$ $ $$ $ $$
$ $$$$ $ $
$ $
$ $ $ $ $ $ $ $$ $ $$ $
$ $ $ $ $ $ $$ $
$$$ $$
$ $ $$$ $ $ $$$$ $ $ $
$ $ $ $ $$ $ $
$ $ $ $ $ $ $$ $ $ $$ $
$ $$$ $$ $ $ $$ $ $ $$ $ $$ $$ $ $ $
$$ $ $
$$ $ $ $$$$$$$$ $ $ $ $$ $
$$ Southeast $$ $ $ $ $
$ $ $ $ $ $ $ $ $
$ $ $ $ $
$$ $ $ $ $ $ $ $$ $ $ $$
$ $$ $$ $ $$
$ $ $ $$ $ $$ $ $ $ $ $
$$ $ $ $$ $$ $ $ $$$ $$ $ $ $ $ $ $$ $ $
$ $ $$ $ $ $$ $ $ $ $$ $ $ $ $ $ $
$$ $ $ $ $$ $ $
$ $$ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $
$ $$ $ $ $ $ $$ $
$ $ $ $$
$ Oak West $ $ $$ $$ $ $ $ $
$
$ $ $ $ Bluitt-Flowers
$ $ $$$$ $
$
$ $ $
$ $$ $ $ $
$ $ $
$
$
$ $
$
Î
Í
Ì20 $ Ú $$ $
Ù175
$ $ $$ $ $
$ Î
Í
Ì
20 $
$
$ $
$
$ $ $$ $
$ $$
$ $ $ $ $
$ $$ $ $ $ $ $ $
$ $ $$$ $ $ $$ $ $ $
$
$ $$ $$ $ $$ $$ $
$ Î
Í
Ì45 $ $
$$ $ $$ $
$
$ $$ $ $
$ $
$ $ $
$ $ $ $$ $
$
$ $ $ $ $ $ $
$ $Ì Î
Í35E
$ $$ $
Ú
Ù 67
$ $ $
$ $ $ $
$ $ $
$ $ $ $
$ $

$ $
$ $ $$ $$$ $$$$ $ $ $
$ $ $ $ $ $
$
WESTLAKE
$ $ $ CARROLLTON
$ $ $ $ $$
$ $ $$ $$
$ $ $ $
$ $
$ $ $ $$
$ $
$ $$ $ $ $
$
$ $$ $$ $ $
$
2000 Census Distribution - Hispanic Population

$
$
$ $ $ $ $
$ $$
$ $ $
$
$
$
$
$
$$
$
$
$
$ $ $$ $
$
SACHSE $ $ $$ $ $
$$
$
$ $ $ $ $ $ $ $$
$ $$ $ $ $$ $ $
$ $
$ $$ $ $ $ $ $ $
RICHARDSON $$ $$ $ $ $
$
$ SOUTHLAKE $ $ $ $
$$$
$ $$
$ $ $
$ $ ADDISON
$$
$
$ $ $$ $ $
$ $ $ $ $ $ $ $
$ $ $ COPPELL $$$$ $$$ $ $$$$ $$ $ $ $ $ $$ $ $$ $
$ $ $ $ $ $$
$
$ $$$$$ $ $ $ $ $ $$$ $$ $ $ $$ $
$ $ $$$$$$$$ $$ $ $ $$ $$$ $ $$$$
$ $ $ $ $ $ $ $ $ $
$ $ $ $$ $
$$$$ $$ $ $ $$$$$
$$
$ $ $$ $$
$$$$$$$$ $ $$ $ $ $$ $ $ $ $ FATE $
KELLER GRAPEVINE $ $$ $ $ $ $$ $
$ $ $$
$ $ $
$ $$
$ $ $ $
$
$
$ $ $ $ $$ $
$$$$$ $$$$ $ $ $ $$$ $
$$ $ $$$
$ $ $ $$$ $$
$$
$$
$ $$$$ $
$ $ $ $
$
$ $ FARMERS BRANCH
$ $ $$ $ $$$$
$ $ $$ $ $$$ $ $ $ $
$ $ $$ $ $$$ $$ $ $ $$ $ $
$ $ $ $ $
$ $
$ $ $
$$ $ $$ $ $$$
$ $
$$ $ $$ $$
$$ $
$$ $ $
$ MOBILE CITY $
$ $ $ $ $ $$ $ Garland
$$ $ $ $ $$ $
$ $$ $$ $$
$ $$$ $$$$$ $ ROWLETT
$$ $ $
ROCKWALL $ $
$ $
$$ $ $ $ $
$ $ $ $$ $
$
$$$$$
$
$$ $$$$ $ $$
$
$
! GARLAND
$ $
$$$
$ $ $ $$ $ $$$ $$ $ $ $$ $ $ $
$$$ $ $$ $ $$$$$ $ $
$$
$$
$
$ $$ $
$$$$ $
$ $ $ $$ $ $ $ $$ $ $ $$ $ $ $ $$
$ $ $ $
$ $ $ $$ $$$ $$ $
$$ $ $ $
$$ $$ $$$$ $ $ $$$ $$ $$$ $ $$$$ $ $$ $
$
$
$$$ $$ $ $$ $ $$$$ $
$$$ $ $ $ $$$ $ $ $
$ $ $ $ $COLLEYVILLE$ $
$ $$ $ $ $ $$$$$$
$$$$$ $$
$
$
$ $
$ $ $
$ $ $ $ $
$$$ $$ $ $ $$
$$$ $
$ $ $ $
$$ $$ $$ Vickery $ $ $$ $$ $ $ $$$ $$ $ $ $ $ $ $ $$ $$$$$ $
$ $$ $$$$$ $ $ $
$$$ $$$ $ $ $$$ $
$$ $$ $ $ $$$$$$ $ $ $ $ $ $ $ $ $ $ $
$ $$ $ $$$$$ $$$$$$ $$$$ $$$ $$
$
$ $ $$ $ $$ $ $ $
$$
$ $
$ $ $ $$$$$ $
$
$ $$ $$
$$
$
$
$
$
$
$
$
$$
$
$
$$
$
$$
$$
$
$$
$$
$$
$
$
$
$
$$$
$$
$
$
$
$
$$
$
$
$$$
$$$$
$ $
$$$ $$$ ! $ $$$$
$
$$$$
$$$
$
$
$$
$$$
$$$
$$$$
$
$
$$
$$$$ $
$
$ $ $$$
$
$
$ $$ $$$
$$$ $$$$$
$$ $
$ $$$ $ $ $ $
$ $
$ $ NORTH RICHLAND HILLS$ $ $ $ $$$$ $
$
$
$$$
$
$
$
$
$$$$$
$$
$$$
$$$$ $ $
$
$$ $ $$ $ $$$ $ $ $ $ $$ $ $ $$
$ $ $
$ $ $ $
$ $ $ $$ $$
$$
$ $$ $
$
$$$$$ $ IRVING $ $$
$$
$
$
$
$
$
$$$
$$$
$$$$ $
$$ $
$ $$ $$ $
$$ $ $
$ $ $
$ $$ $ $$
$$ $$ $ $ $ $ $
$
$
$ $ $ $
$$
$
BEDFORD EULESS
$$ $ $$
$ $ $$ $ $ $ $ $ $
$$ $ $ $$ UNIVERSITY PARK
$ $ $
$ $ $$$ $$$
$$
$ $$$ $
$$$$$ $
$ $ $$
$$ HEATH $ $$ MCLENDON-CHIS $
$$ $ $$ $$ $ $ $ $$ $
$ $$
$$$ $$
$ $ $$
$$ $
$ $$
$ $
$ $
$ $ $ $$$$$$ $ $ $
$ $ $ $ $ $
$
$
$ $ $$ $ $ $$ $ $$ $$ $$ $ $ $$ $$$$ $ $ $
$ $
$ $ $
$$ $$ $$ $ $ $$
$ HURST $ $ $ $$$ $ $ $$
$ $ $
$$$$ $ $ $ $$$ $ $ $ $ $
$$
$ $ $
$ $ $$ $$ $ $ $$$$$ $ $
$
$$$$$$$
$
$ $$ $
Parkland Memorial
$ $
$$$ $$$ $$ $$$ $ $$$
HIGHLAND PARK $ $ $ $
$ $$
$
$ $$$$ $$$ $ $$ $
$
$ $ $ $$ $ $$ $
$ $ $ $ $ $ $ $$$ $ $$
$ $$$ $ $ $$$$ $ $$ $$ $ $$$
$
$
$ $ $ $ $ $ $$$$$$ $ $$$
$ $ $
$ $ $$$ $$ $$
$ $ $$$$
$
$ $ $$
$
$ $ $ $$ $$$$
$ $$
$$
$
$$$$$
$$$ $$$$$ $
$$
$$
$
$ $$ $$
$$$$
$ $
$
$$$$$$$$
$
$$
$$ $ $
$
! $ $$
$ $$ $$$$
$$$$$$$
$
$$$$ $$ $ $ $
$
$$$ $ $$$ $$ $$
$ $
$$$
$$$
$$$$
$$$$
$
$
$
$
$$$
$$
$$
$$$ $ $$
$
$$ $$$$$
$ $
$$$ $ $ $$$$ $
$ $
$$ $$ RICHLAND HILLS
$ $$ $ $
$
$$
$$
$
$
$ $$$$ $
$
$
$ $ $ $$ East
$ $$$ $$$
$ $$
$
$
$
$
$
$$
$ $ $$ $$
$$
$$
$
$
$
$
$$$
$$
$
$$$
$
$ $$$
$$
$$ $ $ $
$
$ $
$
$ $$ $ $ $$ $ $$$
$ $
$ $ $ $ $ $$
$ $
$
$$ $ $ $ $ $ $ $$$
$$$$ $ $ $$ $$$$ $$$ $
$ $ $$ $ $ $$$ $$$$
$ $$ $$$ $ $$$$ $ $$$ $
$
$$$$$$ $ $ $ $$
$$ $ $$ $ $
$
$ $$ $$$
$ $$ $ $$$ $ $$
$$$$ $$
$
$ $$$
$ $
$$$$ $
$$$ $
$ $$$$$ $ $$ $ $ $$ $SUNNYVALE
! &
$$
$ $ $ $ $ $$$
$$
$
$ $$$$$ $$$$$ $ $$$
$ $ $$ $ $$
$ $ $
$$$
$ $
$$ $$ $$ $
DALLAS $
$$ $$
$
$
$
$
$ $$$$$
$
$$$$
$ $
$
$ $$$$ $$$$
$
$
$
$$$$ $$$ $$
$
$$
$
$
$ $ $$ $ $ $ $ $ $ $ $ $$$$
$ $$ $
$
$$ $ $
$ $
$
$$ $ $ $ $ $$$ $$ $$ $$ $$$ $$ $ $
$ $ $ $ $
$ $$$ $ $
$
$
$ $$$$$ $
deHaro
$ $
$ $$$$ $$ $ $$ $ $
$ $$ $ $$ $
$$ $$ $$ $ $$$ $$ $$ $ $
$ $$$$ $ $ $ $ $
$$ $$
$ $$ $$$$ $ $$$ $$ $ $$$ $ $
$ $ $ $$$ $$ $ $ $
$$
$
$$ $$$$ $ $ $$ $ $
$ $
$$ MESQUITE $
$ $$ $ $
$ $$
$ $ $ $$$ $ $ $
$ $$ $$$
$
$ $
$ $$$
$
$
$ $ $$$
$$$
$
$$$
$
$
$
$
$$ $ $$ $ $ ! $$
$
$
$
$$$$
$
$
$$$$
$
$
$
$$
$
$
$
$$$$$$
$ $$$
$$
$ $$$ $$ $
$
$$$$ $$ $
$$
$
$ $
$
$ $ $
$
$ $ $$
$
$ $$
$
$
$
$$ $$ $ $
$
$
$ $$ $ $ $
$$ $ $
$$
$$
$ $
$ $$ $ $
$
$ $
$
$ $ $ $ $ $$ $ $
$$$ $ $$$$ $ $
$ $$ $$$ $ $
$ $ $$$$ $$ $$ $ $$ $ $$ $
$$ $$ $ $$$$$ $$
$$ $ $$$$ $
$ $$ $ $ $$ $
$ $ $$ $$ $$$ $ $ $ $
$ $
$ $ $$$$ $$$ $$$$$$
$
$$
$$ $$$
$$$$$$$$
$$$$
$$ $$
$
$$$
$$
$$
$$$$$$ $
$ $ $$
$
$
$$
$ $$
$$ $
$
$
$
$$$ $
$$$ $$$ $ $$$$$$$ $ $ $
$$$ $ FORNEY $
$ $ $ $ $$
$ $$ $ $$ $ $ $ $ $ $ $$$$$$$ $$$$$$
$$$
$$$ $$$$
$$ $$
$$$ $$$$$$$ $ $$ $ $$ $$
$
$$ $$$ $ $$
$ $$ $ $$ $ $ $$$$ $ $$ $ $$ $$$ $
$$ $ $
$ $$$
$ $$$$ $ $ $
$
$ $ $ $$$ $ $ $ $ $ $$$ $ $ $$$$$$ $ $ $ $$ $$ $
$
$ $$ $$$$$ $$
$
$
$$
$
$ COCKRELL HILL
$$$$$$$
$
$ $$$
$$$
$ $$
$$
$ $ $
$$ $
$
$
$$$
$ $$
$
$$$$$$$
$
$
$ $
$
$
$
$
$
$
$
$$
$
$
$
$ $ $ $
$$$$$
$
$$ $$
$
$ $ $ $
$$ $ $
$
$ $$ $
$ $ $ $
$ $
$ $ $ $$ $$$
$$ $
$
$ $$$$$
$$$ $ $ $ $ $$ $$$
$$
$$$$$$
$
$ $$$
$$$
$ $$
$ $$$$ $
$$$$
$ $ $ $ $ $$ $ $ Southeast $ $$ $ $ $$ $$$$ $$
$$$$ $ $$ $
$ $ $$ $$$ $ $$$$ $$ $$ $ $ $
$ $$
$$ $$ $$ $$$ $$$ $$$$ $ $$ $
$$ $$ $$$
$$$ $$$$$
$ $$$$ $ $ $$
$ $$$ $$ $
$$ $
$$$ $ $ $$ $
$ $ $$ $ $$ $ $$ $$$$ $$$$
$ $$
$
$$ $
$ $$$ $$ $
$ $$ $ $$ $$ $
$$$ $$ $ $$$ $ $ $
$ $$ $$$ $$ $$$$$$$$ $ $$ $ $$$ $ $ $ $
$
$
$$ $ $$$$$
PANTEGO
$ $ $
$$$
$$$$$$
$
$$ $$ $
$
$ $$ $ $ $ $$$ $
$ $ $$$
$$$$$$$
$
$
$ $ $$$$ $
$$$$
$
$$$$
$ $$$ $
$ $
$ $$$
$ $
$
$$$
$
$ $$$
$$$$$$$$$
Bluitt-Flowers
$
$ $ $
$$$
$$$ $ $$
$$ $
$
$
$
$
$$
$$
$$$$
$ $ $
$
$$$
$$$ $$
$
$ $$
$
$$$$
$
$ $$
$$ $ $ $
$ $ $$
$$
$
$
! $ $ $ $ $ $ $$$
$$ $$ $ $ $ $ $$
BALCH SPRINGS $$$
$
$
$
$$
$ $ $
$
$ $$ $ $ $$ $$$
$ $$$$$$ $ $$$ $ $$$ $$$ $$ $$$ $ $$$ $ $$ $ $$ $ $ $$
$ $ $ $ $ $ $$ $ $$ $$ $$
$ $$$$ $ $ $
$
$ $ $$
$$ $
$ $$$ $
$$ $ $
$ $ $ $$ $ $
$
$ $ $ $ $$$ $$ $ $ $ $ $
$$ $ $ $ $$
ARLINGTON $ $$ $ $$$ $$ $$$ $ $$ $$$
$ Oak West
$ $! $$ $ $$ $ $
$ $ $ $ $$ $ $ $ $
$$ DALWORTHINGTON
$
$
$ $ $$ $
GARDENS $ $$$ $ $
$ $ $$ $ $ $ $ $$
$
$ $ $ TALTY $
$ $
!
$
$ $ $ $$ $
$ $ $ $ $
$
$
$
$
$ $
$ $
$
$ $$
$$
$ $
$ $ GRAND PRAIRIE $
$ $
$ $ $ $
$ $
$
$ $$ $
$
$ $ $ $ $ $$ $ $ $$ $
$ $ $$ $ $ $ $$ $$$$ $ $ $$ $ $
$ $ $ $ $$$ $
$ $ $ $ $ $ $ $$ $ $
$ $
$ $ $ $ $ $ $ $ $$
$ $ $$$ $ $$ $
$ $ $
$ $$ $ $ $ $ $ $ $$$ $ $ $ $$ SEAGOVILLE $ $
$$ $ $ $
$ $$ $ $$$ $ $$ $
$ $ $
$$ $
$ $ KENNEDALE $ $ $
$$ $
$
$ $ $ $$ DUNCANVILLE $
$ $ $ HUTCHINS
$
$
$
$ $ $ $ $ $ $$$$ $ $ $
$ $ $ $ $ $ $
$ $$ $ $
$
$$ $
$ $ $
$ $$ $ CRANDALL $
$ $ $
$$
$ $ $ $ $ $ $
$ $ $ $ $ $
$ $ $ $ $
$ $ $ $
$$ $ $ $ $
$ $ $ $ $ DESOTO
$
$ $
$ $ WILMER $
$ LANCASTER $ $ $ $ $
$ $ $ $ $ $
$ $
$
$ $ $
$
Water Area
$$ $ $ $
$ RENDON$ $
$
$ $
$ CEDAR HILL
$
$
$ $ County Line
$ $ $$ $ $ $
$ $$$ MANSFIELD $
$
$
$$$ $
$
$
$
$ $ $ $ $
$
$ ! $ COPC Clinic $
$ $ $ GLENN HEIGHTS
$
$ Dot-Density
$
$ $$ $ $ $ $ FERRIS $ = 200 Persons of Hispanic Origin
$ $
$ OVILLA $
$
$
$
$$

$ $ $$$ $
$ $ $
$ $ $
$ $ $ $ $ $ $ $
$ $ $ $$$ $ $
$ $ $
$ $
CARROLLTON $$ $$$
$ $ $$ $ $$ $
$
$
WESTLAKE $
$
2000 Census Distribution - African American Population

$
RICHARDSON
$ $ $
$
$
$
$ $
$
$
$ SACHSE
$$ $ $
$ COPPELL $
$ $ $$ $ $ $$ $
$ $
$ $ $ $ $ $ $
$
$ SOUTHLAKE $ $ ADDISON $$
$ $
$ $ $
$ $
$ $ $$$ $ $$$$ $
$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $
$$ $
$ $ $$ $ $ $$
$ $
$ $ $
$$
$$
$
$
$
$
$ $ $ $ $$
$
$ $ $ $
$
FATE
$ KELLER $
$ GRAPEVINE $ $ $$$
$ $$
$ $$$$$$ $
$ $
$ $ $ $$ $$ $ $ $ $
$ $ $ $ FARMERS BRANCH $$ $ $ $ $ $ $ $$ $$ $ MOBILE CITY
$ $ $$ $ $$ $$$ $$$$$$$ $ $$$
$
$ $ $ $ $ ROCKWALL
$ $ $ $
$$ $
$ $$ $$ $$$ $ $$ $$ $ Garland $ $$
$ $ $ $ $ ROWLETT
$
$
$ $ $ $ $$ $ $$$$$ $$$$ $
! GARLAND
$ $$ $$$ $ $$ $$ $ $$ $ $ $ $ $
$ $ $ $ $ $ $ $ $$ $
$ $ $ $ $ $ $ $$$$$$
$
$$$
$$ $ $ $ $ $
$ $ $ $
$$$$$$$ $$ $ $ $$ $ $$ $ $$ $ ROC KWALL
$ $ $ $ $ $ $$ $ $ $ $$$ $
$ $ $ $$ $$ $ $
$ COLLEYVILLE $ $
$$
$$ $
$$ $$ $
$ $ $ $ $ $ $
$ $ $
$ $
$ $ Vickery$ $ $$ $$$$
$
$$$ $$ $ $
$ $$$ $ $ $ $$
$ $$ $ $ $
$ $$
$$ $$ $$ $$$ $ $ $
$
$$$ $ $
$
$ $
$ $ $ $ $$
$$
$
$$ $ $ $$
$ $!
$$ $$
$
$
$$
$$$ $
$
$
$$ $
$$ $ $
$$$$$$ $
$
$
$
$ $
$
$ $$$$
$ $ $$$
$ $
$
$$ $
$
$ $$$ $
$ $
$ $
$
$ NORTH RICHLAND HILLS $ $ $ $$ $ $$ $ $ $ $

$ $ $ $ $ $$
$ $ $ $ $
$
$
$ $$ $$$ $$ $$ $
$ IRVING $$$ $
$ $
$ $
$$ $ $
$ $$$ $
$ $ $
$$ BEDFORD EULESS $ $ $ $$ $ $ $ $ $$ $$$ $ UNIVERSITY PARK
$ $ $ $ $ $$
$ $$
$$ $
HEATH $
MCLENDON-CHIS
$$$$ $$
$
$ $$ $ $ $ $$ $ $
$ $ $$ $ $ $ $
$$ $$ $$ $ $
$ $ $$$ $$ $$ $ $
$ $$$ $ $
$$ $$ $ $
$ $$ $ $ $ $ $$ $ $ $$ $$$ $ $
$ HURST $
$
$ $
$ Parkland Memorial
$ $ $ $
HIGHLAND PARK
$
$ $ $
$ $
$
$ $
$ $ $ $ $ $$ $ $$$
$
$ $
$ $ $
$$
$ $ $ $ $ $$$ $$
$
$
$ $ $
$ $ $
$ $$
$
$ ! $ $
$ $$ $
$
$ $ $
$
$$$$$$ $ $
$
$
$ $
$RICHLAND HILLS $ $
$ $
$ $ $$
$ $
$
$$
$
East $$
$ $$ $ $ $
$
$$$ $$$$
$$$$$$$$
$ $$$
$$ $ $$
$ $ $ $$
$
$
$$
$ $ $$ $$$$$$ $
$ $
$ $$ $
$$ $$ $$$ $ $ $ $ $ $$ $$ $ $ $$$$
$$ $ $ SUNNYVALE $
! &
$$
$ $ $ $ $ $
$ $$$ $
$ $ $ $$$ $
$ $
$
$$$ $
$$ $ DALLAS$ $$
$$
$ $ $ $$ $ $ $ $ $ $$$
$
$ $$$ $$$ $$$$$ $ $
$
$ $
$ $
$
$
$
$
$$ $$$$$ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $$ $ $ $$$$$ $ $ $ $$$
$ $$ $
$ $ $
$$ $$$
$ $ $ $$$
$$$$ $
$
$
$
$ $ $
$ deHaro
$ $$$ $ $
$ $ $ $$ $ $$ $ $$
$
$$ $$$$$$$ $$
$$
$ $$ $$$$ $ $ $$ $$
$
$$$ $ $ $ $$$ $$ $$ $ $ $
$$ $ $$ $$ $$ $
$ $$ $ $$ $ $
MESQUITE
$ $ $ $$ DALLAS$ $$ $ $$$ $ $
$$$
$ $
$ $$
$ $$
$$
$$$
$$ $
$
$ $$ $ $
$ $ $$
$
$ $
$
$$ $ $
$
$
$ $
$ $$
$
$$
! $
$ $$ $
$ $$
$
$
$ $$
$$$
$ $
$$
$
$$
$
$
$$ $$
$$$
$ $$$
$$$ $
$ $ $
$
$$ $$ $$ $ $$$
$
$ $
$
$
$$ $$$ $
$ $$
$$
$ $ $ $ $ $ $$ $
$ $
$
$ $ $$ $$$ $$ $ $$$ $
$ $$$ $ $ $ $$$ $$ $ $$ $ $ $$
$ $$ $ $
$$$ $ $$ $$ $ $ $$ $ $ $
$ $$
$
$ $
$ $ $$ $$ $$ $
$
$ $$$$$
$$
$$ $$
$$ $$ $
$
$ $
$ $ $$$$$$ $ $ $
$
FORNEY
$ $ $ $$ $ $ $ $ $ $$$ $$ $ $ $
$ $$$ $$
$ $ $ $$ $
$ $ $$ $ $ $ $
$$$ $$$
$$ $$ $ $ $$ $$
$ $ $$ $ $ $$$ $ $ $
$ $ $ $$ $ $
$
$
$
$ $ $ COCKRELL HILL
$ $ $ $
$ $
$
$$ $ $$$$ $$$$$ $$ $$ $ $ $ $
$ $
$$ $ $ $ $
$
$ $ $ $ $ $
$ $ $
$ $ $$ $ $$$ $ $ $ $
$ $$$ $ $ $
$ $ $ $ $ $ $$$ $$ $ Southeast $ $ $ $ $$
$$$ $
$ $ $ $ $$$ $ $$ $ $$
$$$$$$$ $ $ $$$ $
$ $ $ $ $ $ $
$ $$$$$$$$
$ $$$
$$ $$ $$$$$
$$$ $$$
$ $ $$ $$$$ $$
$ $
$$
$ $ $ $
$
$
$$ $$$
$$$ $$ $ $ $ $ $ $$$$ $$ $$$ $ $ $ $ $ $$$$ $ $ $ $
$$$$$
$$$
$
$ $$
$$
$
$
$ $ $ $$ $ $
PANTEGO $ $
$ $ $$ $$$ $ $
$$$$ $
$ $$ $$ $
$ $
$ $ $$$ $$
$$
$$$$$$
$$Bluitt-Flowers$$
$ $$ $$$$
$ $$ $
$ $
$ $$$$
$$$$ $$$$ $
$$
$ $
$ $ $$
$$$ $
$ $$
$ $$$$ $$$$
$ $$
$$ $
!
$$$ $ $ $ $
$ $
$ $ BALCH SPRINGS
$$ $ $
$
$
$ $ $$$ $$ $$ $$ $$ $$ $
$
$ $ $$$$ $$ $ $$ $ $ $ $ $$ $ $ $ $$ $ $$
$$ $$ $$$$ $
$$$$ $ $$
$$$$ $
$ $
$ $
$$ $$ $ $ $ $
$$ $ $ $ $ $ $ $ $ $$$$ $ $$ $ $ $ $ $$ $ $$ $$ $ $ $
$$ $ $ $ $
ARLINGTON
$ $
DALWORTHINGTON
$$
$ $
$
$ $ $ $$ $
GARDENS
$$ $ $
$$$ $$$ $ $ $
$
$ $
$
$ $ Oak West
$$ $ $$$ $$$$$$
$$ $ $$$ $
$
$
!
$
$
$$$
$ $
$$$ $$$$
$ $$$$
$ $$$
$$ $$$$
$
$
$$ $$ $ $ $
$ $$$ $
$$ $
$$
$ $$$$$
$
$ $ $
$$$$
$$
$ $ $
$
$ $ $
$ TALTY
$$$
$
$ $ $
$$$$$$ $
$ $
!
$
$ $ $ $ $ $ $ $ $$ $$ $ $$ $$$$ $ $ $$ $
$ $ $$$$ $ GRAND PRAIRIE $ $$ $ $ $$ $$$ $$ $ $$$ $ $
$$ $
$ $
$ $ $ $ $$ $
$$ $
$ $$
$ $
$
$$$ $ $
$ $ $$$$ $$$
$$$$$ $
$ $
$ $$$
$ $ $$ $$$ $
$
$ $ $ $
$ $ $ $ $ $$ $ $ $$$ $ $ $ $ $ $
$
$ $
$$$
$$$
$ $$$
$$ $ $ $
$ $ $$$
$ $ $$
$ $ $ $
$
$ $$ $ $$$ $ $ $ $ $$$ $$$$ $ $ $$ $$$ $$$ $ $$ $
$ $ $ $$ $ $ $
$ $ $ $ $$ $ $
$$ $ $ $ $ $ $ $$$ $ $$
$ $ $ $ $$
$
$ $ $$ $ $$$ $ $$ $ $
$ $ $ $ $$ $ $$$ $$$ $ $ $ $$$ $$
$
$ $ $ $$ $ $$$ $ $ $$
$
$ $$$ $$ $$$ $$$ $$$$ $$
$
$
$$$
$$
$ $ $$ $$$$ $
$$ $ $$ $ $$ $$ $ $ $ $
$ $ $SEAGOVILLE
$ $ $ $
$$$$ $ $ $ $ $ $ $
$
$$$$ $
$ $$$ $$ $ $ $ $$ $ $ $$ $$$$ $$$$$ $$$ $ $$ $$ $$ $ $ $
$$ $ $ $ $ $ $$ $$ $ $$ $ $$
$$$
$ $ $ $ $$$
$
KENNEDALE
$ $ $ $
$$ $ $ $
$
$
$ $
$
$$
DUNCANVILLE
$
$
$$$ $
$$$$$$$ $ HUTCHINS
$ $$
$
$ $ $ $
$ $ $ $ $ $$ $ $ $
$ $ $ $$ $ $ $
$ $
$ $$ $ $ $ $
$ $$
$
$
$
$$$
$
$
$ $$
$ $ $
$
$
$$
$
$$
$
CRANDALL
$ $ $$ $ $$$ $ $$$
$ $$$ $ $$$ $$
$
$ $ $$ $ $ $$
$ $ $ $ $$$ $$ $$$ $$$ $$ $
$ $$ $$$$
$ $ $ $$ $$$$ $ $
$ $ $ $$$ $ $ $$$ $
$ $ $ $$$ $
$ $ $ $$$ $ $$
$$ $ $$$ $$
$$ $ $ $ $
$ $$ $ $$ $$ Map layers
$$ $ $ $ $ $$$$$$
DESOTO $$$ $$ $ $ WILMER
$$ $$$ $ $ $
$
$ $ LANCASTER $
$ $ $
$ $
$ $ $$ $
$ $$ $$ $ $ $ $ $
$
$
$ $ $ $$
$$$
$ $
$
$ COMBINE Water Area
$
$$ $ $ $$
RENDON $ $ $$ $ $
CEDAR HILL
$ $ $ $
$$$ County Line
$$ $
$
$ $ $ $$ $ $ $ $
$$$ $ $$ $
$ MANSFIELD
$
$ $
$ $ $ $ $ $ $
$
$ $
$
$
$
$
! COPC Clinic
$ $ $$ $ $ $$ GLENN HEIGHTS Dot-Density
$
$
$
$
OVILLA FERRIS
$
$
$ = 200 African American Persons
$ $

Baylor University Medical Center
3500 Gaston
Dallas, TX 75246
PATIENT DEMOGRAPHICS (2003)

Inpatient Emergency Visits
Category Discharges Percent Category Visits Percent
< 1 year 4,472 10.80% < 1 year 1,214 2.07%
1-4 years 8 0.02% 1-4 years 2,821 4.81%
5-17 years 563 1.36% 5-17 years 5,733 9.78%
18-29 years 4,723 11.40% 18-29 years 13,447 22.93%
30-39 years 5,074 12.25% 30-39 years 10,579 18.04%
40-49 years 5,437 13.13% 40-49 years 9,814 16.74%
50-64 years 8,964 21.64% 50-64 years 8,440 14.39%
65+ years 12,177 29.40% 65+ years 6,590 11.24%
Male 17,056 41.18% Male 26,451 45.11%
Female 24,362 58.82% Female 32,179 54.88%
American Indian 0 0.00% American Indian 0 0.00%
Asian/Pacific 0 0.00% Asian/Pacific 0 0.00%
Black 8,714 21.04% Black 28,522 48.64%
White 27,196 65.66% White 18,944 32.31%
Other 5,507 13.30% Other 11,170 19.05%
Hispanic 3,992 9.64% Hispanic 10,312 17.59%
Not Hispanic 37,426 90.36% Not Hispanic 48,326 82.41%
Total Inpatient 41,418 100.00% Total Emergency 58,638 100.00%
PAYOR MIX (2003)

Payor Charges Percent Payor Charges Percent
Medicare $403,877,400 37.12% Medicare $3,073,487 16.27%
Medicaid/SCHIP $122,215,805 11.23% Medicaid/SCHIP $2,614,159 13.84%
Self-pay/Charity $58,115,034 5.34% Self-pay/Charity $6,983,314 36.96%
Managed Care $416,944,923 38.32% Managed Care $4,979,427 26.35%
All Other $86,933,196 7.99% All Other $1,243,785 6.58%
Total $1,088,086,360 100.00% Total $18,894,172 100.00%
DRG & ICD-9 TOP 10 (2003)

DRG Description ICD-9 Description
391 NORMAL NEWBORN 78650 CHEST PAIN NOS
373 VAGINAL DELIVERY W/O CC 78900 ABDMNAL PAIN UNSPCF SITE
209 MJR JOINT/LIMB REATTACH, LWR EXTREM 490 BRONCHITIS NOS
371 CESAREAN W/O CC 7840 OTH BONE REPAIR/PLAST OP
127 HEART FAILURE & SHOCK 462 ACUTE PHARYNGITIS
359 UTER/ADNEXA , NON-MAL W/O CC 7242 LUMBAGO
14 INTRACRANIAL HEMORAGE & STROKE V583 ATTEN-SURG DRESSNG/SUTUR
89 PNEUMONIA & PLEURISY >17 W CC 8470 SPRAIN OF NECK
500 BACK & NECK PROCED W/O CC 3829 OTITIS MEDIA NOS
390 NEONATE W OTHER SIGN PROBLEMS 4659 ACUTE URI NOS
Health Management Associates Appendix C

Nearest Parkland Clinics
(COPC, WISH, and School based Clinics)
*East Dallas Health Center & Women’s Clinic (.35 miles)

Woodrow Youth & Family Center (2.5 miles)
*Indicates a relationship between Clinic & Hospital
CENSUS (AHA 2001 survey)
Census #: 589
Staffed Beds: 907
INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Patients whose household income is ≤ 200% of the Federal
Poverty Level qualify for a specific level of charity care outlined by a schedule (schedule not
provided).
Medically Indigent Qualifications: For patients whose household income is > 200% FPL,
amount owed to the hospital after third-party payment has been made must be above 50% of
annual income; or for patients whose household income is between 200 – 500% FPL, amount
owed to the hospital after the third-party payment has been made must exceed a percent of
annual income outlined in an income schedule (not provided).
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom?

Currently have 16 ACGME, 11 TSBME, & 1 ADA approved programs. In addition,
5 program affiliations w/ UTSW: Anesthesiology, Nephrology, Orthopaedic
Surgery, Plastic Surgery, Urology
o Which departments have residency programs? 33 residencies & fellowships in total
o How many residents are in each program? 195 Residents & Fellows in total
o Do you operate any resident clinics? If so, please provide the total number of visits and the
payor mix for the clinics. Yes, see below
Payor Mix for 2003 Resident Clinic Visits:

Payor Visits Percent of Visits
Medicaid 3,329 25.4%
Managed Care/Other 681 5.2%
Self-Pay 5,373 41.0%
Medicare 3,709 28.3%
Total 13,093 100.0%

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? The Baylor system
operates: 8 Senior Health Centers, located at: Brookhaven, Casa Linda,
Fairpark, Garland, Hillside, Irving, Mesquite, and Dallas. Plus 1 Tiny Tots Neo-
Natal clinic (serves “graduates” of the BHCS NICUs)
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe.
Informal relationship between Baylor ED and East Dallas COPC for primary care
referrals and some inpatient admissions.
o Do you operate any hospital-supported indigent care clinics? No
TOTAL BED AVAILABILITY (2003)
Bed type Licensed Staffed Available to be staffed*

General med-surg 682 576
Pediatric med-surg 4 4
Obstetrics 79(a) 72
Med-surg ICU 94 86
Cardiac ICU 23 15
Neonatal intensive care 72 72
Neonatal intermediate care - 8
Pediatric intensive care
Burn care
Other special care 12(b) 12
Other intensive care 16 24
Physical rehab
Alcohol/Drug Abuse or Dependency
care
Psychiatric 9 9
Skilled Nursing care
Intermediate Nursing care
Acute long term care
Other long term care
Other care 38 38
Total Beds: 1,029 916
(a) Includes 5 LDRP beds. (b) Separated from 15 Roberts at the request of Dr. Wilson
Weatherford. Reported separately on the TDH/AHA Annual Survey in FY 2002.
THREE-YEAR TRENDS

Inpatient Percent Percent Percent Emergency Percent Percent Percent
Payor Mix (2001) (2002) (2003) Visit Payor Mix (2001) (2002) (2003)
Medicare 38.13% 37.80% 37.12% Medicare 15.65% 15.69% 16.27%
Medicaid/SCHIP 8.61% 10.06% 11.23% Medicaid/SCHIP 10.00% 12.42% 13.84%
Self-pay/Charity 4.49% 5.49% 5.34% Self-pay/Charity 35.52% 36.21% 36.96%
Managed Care 39.40% 38.11% 38.32% Managed Care 30.81% 28.76% 26.35%
All Other 9.37% 8.55% 7.99% All Other 8.01% 6.92% 6.58%
Total Charges: $948,597,800 $987,916,762 $1,088,086,360 Total Charges: $14,515,758 $16,994,553 $18,894,172

Baylor Medical Center at Garland
2300 Marie Curie
Garland, TX 75042

< 1 year 1,736 14.34% < 1 year 2,824 5.34%
1-4 years 8 0.07% 1-4 years 6,824 12.91%
5-17 years 227 1.88% 5-17 years 8,795 16.63%
18-29 years 1,675 13.84% 18-29 years 10,696 20.23%
30-39 years 1,411 11.66% 30-39 years 8,098 15.32%
40-49 years 1,278 10.56% 40-49 years 6,230 11.78%
50-64 years 2,154 17.80% 50-64 years 4,902 9.27%
65+ years 3,615 29.87% 65+ years 4,502 8.52%
Male 4,483 37.04% Male 23,321 44.11%
Female 7,619 62.95% Female 29,544 55.88%
Asian/Pacific 439 3.63% Asian/Pacific 1,500 2.84%
Black 1,337 11.05% Black 10,988 20.78%
White 8,067 66.65% White 25,044 47.37%
Other 2,179 18.00% Other 15,062 28.49%
PAYOR MIX (2003)

All Other $4,163,099 2.56% All Other $549,512 3.72%
Total $162,867,982 100.00% Total $14,752,206 100.00%
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN 78900 ABDMNAL PAIN UNSPCF SITE
373 VAGINAL DELIVERY W/O CC 7806 FEVER
462 REHABILITATION 3829 OTITIS MEDIA NOS
371 CESAREAN W/O CC V643 NO PROC FOR REASONS NEC
359 UTER/ADNEXA, NON-MALIG W/O CC 78650 CHEST PAIN NOS
127 HEART FAILURE & SHOCK 4660 INTESTINAL FIXATION NOS
89 PNEUMONIA & PLEURISY >17 W CC 5990 URIN TRACT INFECTION NOS
390 NEONATE W OTHER SIGN PROBS V583 ATTEN-SURG DRESSNG/SUTUR
88 CRONIC OBSTUCTIVE PULMINARY DISEASE 4659 ACUTE URI NOS
209 MJR JOINT/LIMB REATTCH OF LWR EXTREM 462 ACUTE PHARYNGITIS

- Garland Health Center & Women’s Clinic (2.75 mi)

- Vickery Family Health Center & Women’s Clinic (8.19 mi)
- White Rock Youth & Family Center (6.98 mi)
Census: 130
Staffed Beds: 188
provided).
RESIDENCY PROGRAM

o Which departments have residency programs? Family Practice
o How many residents are in each program? 18

Medicaid/CHIP 3,087 49.0%
Managed Care/Other 2,394 38.0%
Self-Pay 378 6.0%
Medicare 441 7.0%
Total 6,300 100.0%
OUTPATIENT CLINIC
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No

TOTAL BED AVAILABILITY (2003)*
Bed type Licensed Staffed Available to be staffed

Pediatric med-surg
Obstetrics 28 28
Med-surg ICU 19 19
Cardiac ICU
Neonatal intermediate care
Burn care
Other special care
Other intensive care
Physical rehab 24 24
care
Psychiatric
Other care
Total Beds: 220 185
*Source: self reported data
THREE-YEAR TRENDS

Ttl Charges: $145,832,518 $147,116,781 $162,867,982 Total Charges: $8,827,212 $10,388,733 $14,752,206

Baylor Medical Center at Irving
1901 North MacArthur
Irving, TX 75061

< 1 year 2,048 14.67% < 1 year 2,168 5.28%
1-4 years 0 0.00% 1-4 years 4,508 10.99%
5-17 years 171 1.23% 5-17 years 5,874 14.31%
18-29 years 2,059 14.75% 18-29 years 9,689 23.61%
30-39 years 1,577 11.30% 30-39 years 6,607 16.10%
40-49 years 1,519 10.88% 40-49 years 5,111 12.45%
50-64 years 2,550 18.27% 50-64 years 3,779 9.21%
65+ years 4,035 28.91% 65+ years 3,300 8.04%
Male 5,188 37.17% Male 18,328 44.66%
Female 8,771 62.83% Female 22,708 55.34%
Black 1,550 11.10% Black 6,426 15.66%
White 8,963 64.21% White 18,815 45.85%
Other 3,013 21.58% Other 15,010 36.58%
PAYOR MIX (2003)

All Other $7,341,028 3.38% All Other $584,027 4.31%
Total $217,415,204 100.00% Total $13,544,833 100.00%
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN V655 PERSN W FEARED COMPLAINT
373 VAGINAL DELIVERY W/O CC V583 ATTEN-SURG DRESSNG/SUTUR
462 REHABILITATION 3829 OTITIS MEDIA NOS
371 CESAREAN W/O CC 462 ACUTE PHARYNGITIS
127 HEART FAILURE & SHOCK 8470 SPRAIN OF NECK
143 CHEST PAIN 78900 ABDMNAL PAIN UNSPCF SITE
209 MJR JOINT/LIMB REATTCH OF LWR EXTREM 4660 INTESTINAL FIXATION NOS
359 UTER/ADNEXA, NON-MALIG W/O CC 486 PNEUMONIA ORGANISM NOS
520 CERVICAL SPINAL FUSION W/O CC 8472 SPRIAN LUMBAR REGION
89 PNEUMONIA & PLEURISY >17 W CC 7840 OTH BONE REPAIR/PLAST OP

- Family Medicine Clinic (7.23 mi) - Maple Women’s Health Center (7.23 mi)
- Pediatric Primary Care Center (7.23 mi)
CENSUS (AHA 2001 Survey)
Census #: 138
Staffed Beds: 226
provided).
RESIDENCY PROGRAM
There is no residency program at this hospital.
OUTPATIENT CLINIC
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No.
However, Baylor has proposed to contribute funds to establish a new COPC site
in Irving.


Coronary Care Unit 12 14
Day Surgery Unit
Holdover Unit
Intensive Care Unit 14 14
Labor and Delivery 13 13
MS2 Neurology 12 12
Ortho Neuro 26 26
Med/Surg 24 24
Med/Surg Oncology 21 21
Neuro ICU 12
Neonatal/Special Care Dept. 10 10
Patient Care Unit 14 22
Post Partum 11 11
Rehab 18 18 18
Telemetry 33 33
Newborns (bassinets) 30 30
Total Beds: 288 238 260
THREE-YEAR TRENDS

Ttl Charges: $174,721,083 $203,634,914 $217,415,204 Total Charges: $9,622,172 $10,941,819 $13,544,833

Children’s Medical Center Dallas
1935 Motor St
Dallas, TX 75235

< 1 year 4,428 29% < 1 year 25,405 26%
1-4 years 4,335 28% 1-4 years 37,394 38%
5-17 years 6,461 42% 5-17 years 35,341 36%
18-29 years 194 1% 18-29 years 540 1%
30-39 years 2 0% 30-39 years 121 0%
40-49 years 0 0% 40-49 years 75 0%
50-64 years 0 0% 50-64 years 53 0%
65+ years 1 0% 65+ years 13 0%
Male 8,657 56% Male 53,817 54%
Female 6,764 44% Female 45,125 46%
American Indian 3,036 20% American Indian 24,795 25%
Asian/Pacific 161 1% Asian/Pacific 781 1%
Black 5,812 38% Black 16,949 17%
White 5,676 37% White 52,880 53%
Other 19 0% Other 94 0%
Hispanic 5,676 37% Hispanic 52,880 53%
Not Hispanic 9,745 63% Not Hispanic 46,062 47%
Total Inpatient 15,421 100% Total Emergency 98,942 100%
PAYOR MIX (2003)

Medicare $4,079,528 1% Medicare $53,131 0.10%
Medicaid/SCHIP $348,415,924 60% Medicaid/SCHIP $33,580,583 60%
Self-pay/Charity $6,056,868 1% Self-pay/Charity $6,892,930 12%
Managed Care $193,522,117 33% Managed Care $13,731,272 25%
All Other $28,867,223 5% All Other $1,426,277 3%
Total $580,941,660 100% Total $55,669,948 100%
DRG & ICD-9 TOP 10 (2003)

98 BRONCHITIS & ASTHMA AGE 0 – 17 382.9 OTITIS MEDIA NOS
389 FULL TERM NEONATE W/ MJR PRB 465.9 ACUTE URI NOS
26 SEIZURE & HEADACHE AGE 0 – 17 79.99 VIRAL INFECTION NOS
91 SIMPLE PNEUMONIA & PLEURISY 780.6 FEVER
184 ESOPH, GASTR & DIGEST DISORDERS 558.9 NONINF GASTROENTERIT NE
396 RED BLOOD CELL DISORDERS AGE 0 – 17 493.9 Asthma – unspecified
21 VIRAL MENINGITIS 466.19 ACU BRNCHL TS D/T OTH OR
298 NUTRIT & METABOLIC DISORDERS 486 PNEUMONIA ORGANISM NOS
3 CRANIOTOMY AGE 0 – 17 462 ACUTE PHARYNGITIS
279 CELLULITIS 0 – 17 464.4 CROUP

Nearest Parkland COPC Clinics
- Pediatric Primary Care Center, On Campus - East Dallas Health Center 5.22 Miles
- Family Medicine Clinic, On Campus
CENSUS & LENGTH OF STAY
Average Occupancy* (2003): 70.64%

Average Length of Stay (2003): 4.83 days
*Excludes Obs.
Financially Indigent Qualifications: Patient’s total gross family income must fall below 200%
of the Federal Poverty level, must reside within Children’s service area, and have “exhausted all
reasonable efforts to obtain third party assistance”.
Medically Indigent Qualifications: A monthly payment schedule no longer than sixty (60)
months in length will be set up between the patient’s parent/guardian that reflects a reasonable
monthly burden (general guidelines are 10% to 20% of monthly income on a graduated scale).
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Yes,
Children’s Medical Center is affiliated with the University of Texas Southwestern
Medical Center at Dallas
o Which departments have residency programs? Not available.
o How many residents are in each program? Children’s Medical Center currently has 82
residents and 3 chief residents.
payor mix for the clinics.

Medicaid/CHIP 7,922 84.7%
Managed Care 717 7.7%
Self-Pay/Charity 614 6.6%
All Other 89 1.0%
Medicare 6 0.1%
Total 9,348 100.0%
OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? Outpatient clinics
encompass 59 specialties
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. COPC
pediatricians supervise CMC residents at the clinics, attend on inpatient units at
CMC, and refer their patients to CMC for emergencies, specialties, and inpatient
care.
o Do you operate any hospital-supported indigent care clinics? No.

TOTAL BED AVAILABILITY (2003)^

General med-surg
Obstetrics
Med-surg ICU 33 44
Cardiac ICU 13 17
Neonatal intensive care
Pediatric intensive care 46*
Burn care
Other special care 63 68
Physical rehab
care
Psychiatric 12 12
Other care Total: 348 Total: 258 Total: 291
*reflects beds already counted in the Med-surg & Cardiac IUCs, not additional beds.
^Self reported data
THREE-YEAR TRENDS

Inpatient Payor Percent Percent Percent Emergency Visit Percent Percent Percent
Mix (2001) (2002) (2003) Payor Mix (2001) (2002) (2003)
Total $402,153,583 $460,069,775 $580,941,660 Total $42,007,516 $49,034,184 $55,669,948

Medical City Hospital
7777 Forest Lane
Dallas, TX 75230

< 1 year 4,131 16.3% < 1 year 2,600 6.8%
1-4 years 959 4.6% 1-4 years 4,883 12.7%
5-17 years 1,806 6.4% 5-17 years 6,571 17.1%
18-29 years 2,530 9.9% 18-29 years 7,972 20.7%
30-39 years 3,221 12.9% 30-39 years 6,040 15.7%
40-49 years 2,681 10.7% 40-49 years 4,441 11.6%
50-64 years 4,047 16.0% 50-64 years 3,416 8.9%
65+ years 5,838 23.2% 65+ years 2,512 6.5%
Male 10,051 39.9% Male 16,983 44.2%
Female 15,162 60.1% Female 21,452 55.8%
Black 3,897 15.5% Black 12,588 32.8%
White 16,331 64.8% White 16,294 42.4%
Other 4,383 17.4% Other 8,934 23.2%
PAYOR MIX (2003)

Payor Charges Percent Payor Charges*** Percent
Total $916,627,160 100.0% Total $342,146,199 100.0%
*** Total ER IP & OP account charges (not just ER charges)
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN 382.9 UNSPECIFIED OTITIS MEDIA
373 VAGINAL DELIVERY W/O CC 465.9 ACUTE URI NOS
371 CESAREAN W/O CC 079.99 VIRAL INFECTION NOS
359 UTER/ADNEXA, NON-MAL W/O CC 789.00 ABDMNAL PAIN UNSPCF SITE
098 BRONCHITIS & ASTHMA AGE 0-17 558.9 NONINF GASTROENTERIT NEC
462 REHABILITATION 462 ACUTE PHARYNGITIS
390 NEONATE W OTHER SIGN PROBLEMS 466.0 ACUTE BRONCHITIS
517 PERC CARDIO W NON-DRUG ELUTNG W/O AMI 784.0 HEADACHE
209 MJR JOINT/LIMB REATTACH, LWR EXTREM 786.50 UNSPECIFIED CHEST PAIN
127 HEART FAILURE & SHOCK 847.0 NECK SPRAIN

Census #: 329
Staffed Beds: 530
No policy currently exists, but one is in the process of being drafted.
RESIDENCY PROGRAM

Affiliated with UTSW for OB/Gyn only
o Which departments have residency programs? OB/GYN Only – limited scope
o How many residents are in each program? 1-3 per year
o Do you operate any resident clinics? If so, please provide the total number of visits and
the payor mix for the clinics. No
OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? None
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. NA
o Do you operate any hospital-supported indigent care clinics? NA

General med-surg 223 123 123 due to construction
Obstetrics 47 47
Med-surg ICU 32 32
Cardiac ICU 18 18
Neonatal intermediate care 10 8 10
Pediatric intensive care 14 14
Burn care 0 0
Other special care 61 61
Other intensive care 10 10
Alcohol/Drug Abuse or Dependency 0 0
care
Psychiatric 0 0
Skilled Nursing care 0 0
Intermediate Nursing care 0 0
Acute long term care 0 0
Other long term care 0 0
Other care 9 + 38 NBN
Total Beds: 581 432

THREE-YEAR TRENDS
Inpatient *^ Emergency Visits *^

Inpatient Percent Percent Percent Emergency Visit Percent Percent Percent
Payor Mix (2001) (2002) (2003) Payor Mix (2001) (2002) (2003)
Medicare 19.8% 21.8% 23.0% Medicare 11.6% 11.9%
Medicaid/SCHIP 4.6% 5.1% 5.6% Medicaid/SCHIP 5.5% 7.1%
Self-pay/Charity 2.5% 2.4% 2.8% Self-pay/Charity 20.3% 20.1%
Managed Care 70.7% 68.0% 66.5% Managed Care 57.6% 57.2%
All Other 2.4% 2.8% 2.2% All Other 5.0% 3.8
Total Charges: $632,488,759 $799,723,026 $916,627,160 Total Charges: $285,604,730 $342,146,199
*^ Percentages based from Admit/Visit Volumes (not charges)

Methodist Charlton Medical Center
350 W Wheatland Rd
Dallas, TX 75237

< 1 year 2,334 15.83% < 1 year 2,103 4.37%
1-17 years 326 2.21% 1-17 years 12,100 25.12%
18-24 years 1,413 9.59% 18-24 years 7,346 15.25%
25-39 years 2,425 16.45% 25-39 years 11,706 24.30%
40-54 years 2,425 16.45% 40-54 years 8,291 17.21%
55-64 years 1,615 10.96% 55-64 years 2,869 5.96%
65+ years 4,203 28.51% 65+ years 3,752 7.79%
Male 5,018 34.04% Male 19,695 40.89%

Female 9,723 65.96% Female 28,472 59.11%
Black 6,231 42.26% Black 30,533 63.39%
White 6,890 46.74% White 12,832 26.64%
Other 1,539 10.44% Other 4,639 9.63%
PAYOR MIX (2003)

Total $153,335,510 100.00% Total $44,474,324 100.00%
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN 78900 ABDMNAL PAIN UNSPCF SIT
373 VAGINAL DELIVERY W/O CC 3829 OTITIS MEDIA NOS
371 CESAREAN W/O CC 4660 ACUTE BRONCHITIS
143 CHEST PAIN 49390 ASTHMA W/O STATUS ASTHM
127 HEART FAILURE & SHOCK 4659 ACUTE URI NOS
89 PNEUMONIA & PLEURISY >17 W CC 78659 CHEST PAIN NEC
390 NEONATE W OTHER SIGN PROBS 07999 VIRAL INFECTION NOS
359 UTER/ADNEXA, NON-MALIG W/O CC 8470 SPRAIN OF NECK
88 CRONIC OBSTUCTIVE PULMINARY DISEASE 462 ACUTE PHARYNGITIS
209 MJR JOINT/LIMB REATTCH OF LWR EXTREM 5990 URIN TRACT INFECTION NO

- Oak West Health Center & Women’s Clinic (3.9 mi)

- Red Bird Youth Family Health Center (5.43 mi)
- Old Kaiser clinic (5.17 mil)
Census #: 121
Staffed Beds: 163
Financially Indigent Qualifications: Uninsured/underinsured patients w/ income ≤ the Federal

Poverty Level & a demonstrated inability to pay.
Medically Indigent Qualifications: Patients whose medical bills, after third-party payment, would
require use of income/assets critical to living or earning a living.
Other Factors: No Charity care determinations will be made until the patient has received at
least one balance due statement that gives no indication of possible charity care status. The
patient will continue to receive balance due statements until charity status is determined & it is
clear that further statements will not result in payment. The hospital may notify a patient that
they are under consideration for charity care if “doing so will enhance the public’s
understanding of the hospital’s charity care or assist in the collection of a portion of the
account”.
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Free-
standing with the exception of the Family Practice residency which is affiliated
with UT Southwestern Medical School
o Which departments have residency programs? Family Practice & Sports Medicine
o How many residents are in each program? Family Practice 18; Sports Medicine 2

Managed Care 2,631 21.1%
Self-Pay 1,345 10.8%
All Other 904 7.3%
Total 12,457 100.0%

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located?
3 Family Health Centers:
i. Cedar Hill – 326 B. Cooper St, Cedar Hill, TX 75104
ii. Central Grand Prairie – 820 S Carrier Parkway, Grand Prairie, TX 75051
iii. South Grand Prairie – Westchester Market Shopping Center, 4116 S Carrier
Parkway, Suite 250, Grand Prairie, TX 75052

Pediatric med-surg
Obstetrics 35
Med-surg ICU 24 24
Cardiac ICU
Burn care
Other special care
Physical rehab
care
Psychiatric
Other care
Total Beds: 215 207
THREE-YEAR TRENDS

Total Charges: 96,803,501 127,199,649 $153,335,510 Total Charges: $28,712,984 $37,312,451 $44,474,324

Methodist Dallas Medical Center
1441 N Beckley Ave
Dallas, TX 75203

< 1 year 3,309 16.59% < 1 year 1,948 4.21%
1-17 years 439 2.20% 1-17 years 9,399 20.31%
18-24 years 2,016 10.11% 18-24 years 6,724 14.53%
25-39 years 3,512 17.61% 25-39 years 11,503 24.86%
40-54 years 3,246 16.27% 40-54 years 8,899 19.23%
55-64 years 2,255 11.30% 55-64 years 3,170 6.85%
65+ years 5,170 25.92% 65+ years 4,634 10.01%
Male 7,814 39.17% Male 19,659 42.48%

Female 12,133 60.83% Female 26,618 57.52%

Black 6,386 32.01% Black 21,111 45.62%
White 6,157 30.87% White 7,272 15.71%
Other 7,277 36.48% Other 17,761 38.38%

PAYOR MIX (2003)

Medicare 131,826,177 41.17% Medicare 10,616,042 21.14%
Medicaid/SCHIP 54,505,389 17.02% Medicaid/SCHIP 7,423,476 14.78%
Self-pay/Charity 28,473,294 8.89% Self-pay/Charity 16,268,349 32.40%
Managed Care 85,696,253 26.76% Managed Care 11,683,094 23.27%
All Other 19,729,017 6.16% All Other 4,221,574 8.41%
Total 320,230,130 100.00% Total 50,212,535 100.00%
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN 3829 OTITIS MEDIA NOS
373 VAGINAL DELIVERY W/O CC 4659 ACUTE URI NOS
462 REHABILITATION 78659 CHEST PAIN NEC
371 CESAREAN W/O CC 4660 ACUTE BRONCHITIS
372 VAGINAL DELIVERY W CC DIAGNOSES 5990 URIN TRACT INFECTION NO
127 HEART FAILURE & SHOCK 78900 ABDMNAL PAIN UNSPCF SIT
89 PNEUMONIA & PLEURISY > 17 W CC 462 ACUTE PHARYNGITIS
296 NUTRI & METABOLIC DISORDERS >17 W CC 8470 SPRAIN OF NECK
14 INTERCRANIAL HEMORAGE & STROKE 7840 HEADACHE
359 UTER/ADNEXA, NON-MALIG W/O CC 5589 NONINF GASTROENTERIT NE

Nearest Parkland/Community Clinics
- De Haro-Saldivar Health Center (4.07 mi) - West Dallas Youth & Family Clinic (2.91
- Bluitt-Flowers Health Center (4.65 mi) mi)
- Lakewest Women’s Health Center (4.18 mi) - *Los Barrios Unidos Comm. Clinic
- North Oak Cliff Youth & Family Center (2.55 mi) (FQHC) (2.14 mi)
Census #: 275
Staffed Beds: 360
Financially Indigent Qualifications: Uninsured/underinsured patients w/ income ≤ the Federal

Poverty Level & a demonstrated inability to pay.
Medically Indigent Qualifications: Patients whose medical bills, after third-party payment, would
require use of income/assets critical to living or earning a living.
Other Factors: No Charity care determinations will be made until the patient has received at
least one balance due statement that gives no indication of possible charity care status. The
patient will continue to receive balance due statements until charity status is determined & it is
clear that further statements will not result in payment. The hospital may notify a patient that
they are under consideration for charity care if “doing so will enhance the public’s
understanding of the hospital’s charity care or assist in the collection of a portion of the
account”.
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Free-
standing with the exception of the Family Pratice residency which is affiliated
with UT Southwestern Medical School
o Which departments have residency programs? Internal Medicine, OB/GYN, Gen
Surgery, Anesthesia
o How many residents are in each program? IM = 21, OB/GYN = 11, Gen Surg = 12,
Anesthesia = 3

Managed Care 1,053 9.5%
Self-Pay 3,573 32.3%
All Other 488 4.4%
Total 11,064 100.0%

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? 3 Family Health Centers:
i. Cedar Hill – 326 B. Cooper St, Cedar Hill, TX 75104
ii. Central Grand Prairie – 820 S Carrier Parkway, Grand Prairie, TX 75051
iii. South Grand Prairie – Westchester Market Shopping Center, 4116 S Carrier
Parkway, Suite 250, Grand Prairie, TX 75052

Pediatric med-surg
Obstetrics 41
Med-surg ICU 35 32
Cardiac ICU 16 16
Burn care
Other special care
care
Psychiatric
Skilled Nursing care 20 20
Other care
Total Beds: 493 399
THREE-YEAR TRENDS

Total Charges: 215,253,579 265,152,683 320,230,130 Total Charges: 27,108,779 38,329,849 50,212,535

Presbyterian Hospital of Dallas
8200 Walnut Hill Lane
Dallas, TX 75231

< 1 year 1,120 3.66% < 1 year 3,669 5.96%
1-4 years 86 0.28% 1-4 years 7,244 11.77%
5-17 years 342 1.12% 5-17 years 6,748 10.96%
18-29 years 4,454 14.56% 18-29 years 15,673 25.46%
30-39 years 4,768 15.58% 30-39 years 9,801 15.92%
40-49 years 3,421 11.18% 40-49 years 7,041 11.44%
50-64 years 5,424 17.73% 50-64 years 5,440 8.84%
65+ years 10,979 35.89% 65+ years 5,940 9.65%
Male 9,957 32.55% Male 25,050 40.69%
Female 20,637 67.45% Female 36,506 59.31%
Black 3,512 11.48% Black 18,370 29.84%
White 21,693 70.91% White 22,810 37.06%
Other 2,818 9.21% Other 9,060 14.72%
PAYOR MIX (2003)

Total $731,596,797 100.00% Total $55,099,493 100.00%
DRG & ICD-9 TOP 10 (2003)

373 VAGINAL DELIVERY W/O COMPLICATIONS 382.9 OTITIS MEDIA NOS
371 CESAREAN W/O COMMPLICATIONS 465.9 ACUTE URI NOS
462 REHABILITATION 780.6 FEVER
209 MJR JOINT/LIMB REATTCH OF LWR EXTREMITY 466.0 INTESTINAL FIXATION NOS
359 UTER/ADNEXA, NON-MALIG W/O CC 462 ACUTE PHARYNGITIS
127 HEART FAILURE & SHOCK 784.0 OTHER BONE REPAIR/PLAST OP
517 PERC CARDIO W NN-DRG ELUT STENT WO AMI 786.50 CHEST PAIN NOS
430 PSYCHOSES 920 CONTUSION FACE/SCALP/NECK
25 SEIZURE & HEADACHE AGE >17 W/O CC 599.0 URIN TRACT INFECTION NOS
14 INTRACRANIAL HEMRRGE & SROKE W INFRCTN 789.00 ABDOMINAL PAIN UNSPCF SITE

*Vickery Family Health Center & Women’s Clinic (1.24 mi)

East Dallas Health Center & Women’s Clinic (7.76 mi)
Kiosco Youth & Family Center (5.12 mi)
Woodrow Youth & Family Center (6.84 mi)
CENSUS (2004)
Census #: 460
Staffed Beds: 695
Financially Indigent Qualifications:

If the patient’s gross annual income is ≤ 100% of the Federal Poverty level and they lack
sufficient funds/assets to pay without incurring a financial hardship, they qualify for a charity
adjustment of 100% unpaid charges
If the patient’s gross annual income is 100% - 200% of the Federal Poverty level and they lack
sufficient funds/assets they qualify for a charity adjustment to be determined by the Charity
committee
Medically Indigent Qualifications: Qualifying patients have unpaid medical bills that exceed 3%
- 15% of income (determined on a sliding scale by income bracket) & have insufficient
funds/assets to pay remaining charges. Eligibility for full or partial adjustment determined by
Charity committee.
Other Circumstances: Charity committee has authority to grant full or partial charity to any
patient otherwise deemed to be unable to pay their medical bill rather than unwilling to pay.
Charity committee must reach majority consensus in these cases.
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? One
freestanding, One affiliated with UT Southwestern & Parkland
o Which departments have residency programs? Internal Medicine & Colon Rectal
Surgery (Parkland & UTSW)
o How many residents are in each program? IM – 24, Colon – 1
Do you operate any resident clinics? If so, please provide the total number of visits and the
payor mix for the clinics. No
OUTPATIENT CLINIC
SW Diagnostic Imaging Center – 8230 Walnut Hill Ln – Dallas, TX 75231
Surgery Center Southwest – 8230 Walnut Hill Ln – Dallas, TX 75231
Westmoreland Clinic – 1350 N Westmoreland Rd – Dallas, TX 75211
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. Yes.
Presbyterian provides rent and operating support to Vickery COPC.
o Do you operate any hospital-supported indigent care clinics? No.

TOTAL BED AVAILABILITY

General med-surg 559 378 378
Pediatric med-surg 31 20 20
Obstetrics Med/Surg 86 86
Med-surg ICU 30 30 30
Cardiac ICU 10 10 10
Neonatal intensive care 68 68 68
Neonatal intermediate care NA
Pediatric intensive care NA
Burn care NA
Other special care NA
Other intensive care NA
Physical rehab 52 52 52
Alcohol/Drug Abuse or Dependency NA
care
Psychiatric 89 24 24
Skilled Nursing care 27 27 27
Intermediate Nursing care NA
Acute long term care NA
Other long term care NA
Other care NA
Total Beds: 866 695 695
THREE-YEAR TRENDS

Inpatient Emergency Visit
Percent Percent Percent Percent Percent Percent
Payor Mix Payor Mix
(2001) (2002) (2003) (2001) (2002) (2003)
(As % of Charges) (As % of Charges)
Total Charges: $543,190,555 $622,950,070 $731,596,797 Total Charges: $47,643,620 $47,993,625 $55,099,494

St. Paul University Hospital
5909 Harry Hines Blvd
Dallas, TX 75235

Inpatient Outpatient
< 1 year 3,268 18.8% < 1 year 1,220 1.7%
1-4 years - 0.0% 1-4 years 1,328 1.8%
5-17 years 255 1.5% 5-17 years 2,714 3.7%
18-29 years 3,080 17.7% 18-29 years 13,202 17.9%
30-39 years 2,171 12.5% 30-39 years 10,370 14.0%
40-49 years 2,047 11.8% 40-49 years 12,286 16.6%
50-64 years 2,878 16.6% 50-64 years 16,379 22.2%
65+ years 3,663 21.1% 65+ years 16,428 22.2%
Male 6,051 34.9% Male 50,385 68.2%
Female 11,311 65.1% Female 23,542 31.8%
Black 4,058 23.4% Black 20,707 28.0%
White 7,679 44.2% White 28,086 38.0%
Other 5,422 31.2% Other 24,492 33.1%
Total Inpatient 17,362 100.0% Total Outpatient 73,927 100.0%
PAYOR MIX (2003)

Total $303,419,689 100.0% Total $91,203,175 100.0%
DRG & ICD-9 TOP 10 (2003)

391 NORMAL NEWBORN V76.12 SCREENING MAMMOGRAM
373 VAGINAL DELIVERY X/COMPLICATIONS 401.9 HYPERTENSION NOS
390 NEONATE W/SIGNIFICANT PRO V58.49 POST-OP AFTERCARE NEC
430 PSYCHOSES V22.1 SUPERVIS OTH NORMAL PREG
127 HEART FAILURE & SHOCK 250.00 DIABETES UNCOMPL TYPE II
371 CESAREAN SECTION X/CC 789.00 ABDOM PAIN NOS SITE
370 CESAREAN SECTION W/CC V57.1 PHYSICAL THERAPY NEC
209 MAJOR JOINT LIMB REATTACH 789.09 ABD PAIN NEC/MULTI SITE
462 REHABILITATION 786.2 COUGH
372 VAGINAL DELIVERY COMPLICATIONS 786.50 CHEST PAIN NOS

Census #: 193
Staffed Beds: 145
Financially Indigent: An uninsured or underinsured person who qualifies for charity care under the
hospital eligibility system will be accepted for care with no obligation or a discounted obligation to pay
for services rendered. The income eligibility portion shall not be set lower than the legal limit or higher
than 200% of the Federal Poverty level.
Medically Indigent: “A person whose medical or hospital bills, after payment by third-party payers,
exceed a specified percentage of the patient’s annual gross income, determined in accordance with St.
Paul Medical Center’s eligibility system, and the person is financially unable to pay the remaining bill.”
A combined Charity Policy for St. Paul and Zale is being finalized and should be in effect by
the end of year.
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Our residency
programs are affiliated with the University of Texas Southwestern Medical School in Dallas.
o Which departments have residency programs? During the 2003-2004 academic year
(07/01/03 to 06/30/04), St. Paul sponsored residency programs in the following
departments:
♦ Family Practice
♦ Internal Medicine
♦ Obstetrics and Gynecology
o How many residents are in each program? During the 2003-04 academic year (07/01/03 to
06/30/04), the number of residents in each of the residency training programs was:
♦ Family Practice – Number of Approved Positions = 12, Number filled = 11

♦ Internal Medicine – Number of Approved Positions = 19, Number filled = 19
♦ Ob/Gyn – Number of Approved Positions = 12, Number filled = 12
o Do you operate any resident clinics? If so, please provide the total number of visits and the payor
mix for the clinics. For 2003: IM 4,505, Surg 203, Gyn 1,924, OB 9,723

For St. Paul Clinic Only
Payor Visits* Percent of Visits

Medicaid 60.16%
Managed Care/Other 7.13%
Self-Pay 28.55%
Medicare 4.16%
Total 100.0%
*unable to provide due to systems constraints

OUTPATIENT CLINIC
5909 Harry Hines Blvd: St. Paul Clinic
5550 Harvest Hill Road: Family Practice Clinic
o Do you operate any hospital-supported indigent care clinics?
No; only clinics are for the residency programs.

Pediatric med-surg
Obstetrics
Cardiac ICU 23 18 5
Neonatal intensive care 34 24 10
Burn care
Other special care
Alcohol/Drug Abuse or Dependency 14 0 14
care
Psychiatric 64 0 64
Other care
Total Beds: 550 303 247
*Source: Self reported data
THREE-YEAR TRENDS
Inpatient Percent Percent Percent Outpatient Percent Percent Percent
Payor Mix (2001) (2002) (2003) Payor Mix (2001) (2002) (2003)
Medicare 37% 40.9% 42.0% Medicare 28.5% 31.3% 31.9%
Medicaid/SCHIP 7% 11.0% 13.5% Medicaid/SCHIP 4.4% 5.9% 6.4%
Self-pay/Charity 5% 3.3% 3.6% Self-pay/Charity 9.8% 8.0% 11.6%
Managed Care 38% 34.9% 35.3% Managed Care 45.7% 43.7% 44.1%
All Other 13% 9.9% 5.6% All Other 11.7% 11.1% 6.0%

Zale Lipshy University Hospital
5151 Harry Hines Blvd
Dallas, TX 75235

Inpatient Outpatient*
< 1 year 0 0.0% < 1 year 13 0.1%
1-4 years 0 0.0% 1-4 years 2 0.0%
5-17 years 52 0.8% 5-17 years 164 1.2%
18-29 years 378 6.1% 18-29 years 982 7.0%
30-39 years 605 9.8% 30-39 years 1,704 12.1%
40-49 years 1,152 18.6% 40-49 years 2,722 19.3%
50-64 years 1,961 31.6% 50-64 years 4,324 30.7%
65+ years 2,057 33.2% 65+ years 4,181 29.7%
Male 2,754 44.4% Male 6,366 45.2%
Female 3,451 55.6% Female 7,726 54.8%
Black 607 9.8% Black 1,329 9.4%
White 5,151 83.0% White 11,587 82.2%
Other 375 6.0% Other 953 6.8%
Hispanic 302 4.9% Hispanic 640 4.5%
Total Inpatient 6,205 100.0% Total Outpatient 14,092 100.0%
PAYOR MIX (2003)

Medicaid/SCHIP $3,899,854 2.3% Medicaid/SCHIP $604,829 1.3%
Self-pay/Charity $2,011,439 1.2% Self-pay/Charity $848,136 1.9%
Total $166,856,899 100.0% Total $44,879,646 100.0%
DRG & ICD-9 TOP 10 (2003)

462 REHABILITATION 366.9 CATARACT NOS
430 PSYCHOSES No Code
002 CRAINOTOMY AGE >17 W/O CC 592 CALCULUS OF KIDNEY
001 CRAINOTOMY AGE >17 W CC 174.9 MALIGN NEOPL BREAST NOS
288 MJR THUMB/JOINT OR HAND/WRIST PROC W CC 188.9 MALIG NEO BLADDER NOS
209 MJR JOINT/LIMB REATTACH, LWR EXTREMITY 189 MALIG NEOPL KIDNEY
303 KIDNY/URTR & MJR BLADDR PROC FOR NEOPLAS 296.3 RECURR DEPR PSYCHOS-UNSP
500 BACK & NECK PROCEDURE W/O CC 437.3 NONRUPT CEREBRAL ANEURYM
148 MAJR SM & LR BOWEL PROC W CC 185 MALIGN NEOPL PROSTATE
520 CERVICAL SPINAL FUSION W CC 174.8 MALIGN BEOPL BREAST NOS

Census #: 114
Staffed Beds: 145
Financially Indigent Qualifications: If the patient’s family income is less than or equal to 200%
of the Federal Poverty Level for the family’s size, the patient qualifies for charity care equaling
100% of patient’s balance.
Medically Indigent Qualifications: If amount owed after third party payment exceeds
percentage of family income specified by hospital then the patient would qualify for a portion of
bill to be written off as charity care. (table describing income/payment breakdown not
provided)
A combined Charity Policy for St. Paul and Zale is being finalized and should be in
effect by the end of year.
RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? Affiliated. If affiliated, with

whom? Our residency programs are affiliated with the University of Texas
Southwestern Medical School in Dallas.
o Which departments have residency programs?
o Anesthesiology: 8 o Oral Surgery: 1
o Internal Medicine: 6 o Orthopedics: 2
o General Surgery: 6 o Otolaryngology: 2
o Neurology: 2 o Pathology: 1
o Physical Medicine: 2 o Plastic Surgery: 2
o Neurosurgery: 4 o Psychiatry: 3
o OB/Gyn: 0.25 o Urology:
o Ophthalmology: 2
o How many residents are in each program? See above

o Do you operate any resident clinics? No If so, please provide the total number of visits and
the payor mix for the clinics.
OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? N/A
o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. N/A
o Do you operate any hospital-supported indigent care clinics? N/A


Pediatric med-surg
Obstetrics
Cardiac ICU
Burn care
Other special care
Alcohol/Drug Abuse or Dependency care
Psychiatric 21 21 0
Other care
Total Beds: 152 152 0
THREE-YEAR TRENDS
Inpatient Percent Percent Percent Outpatient Percent Percent Percent
*Includes Health Center and Day Surgery.
Laser Eye Center was moved under UT in
July 2003

Project Access
Project Access is a physician-led community effort to provide health care to low-income,

employed but uninsured residents of Dallas County. It is managed by the Dallas County
Medical Society and operates through a network of volunteer physicians and hospitals.
Project Access provides both primary and specialty care, as well as access to
pharmaceuticals, lab tests and other ancillary services (see summary below).
Project Access is funded through grants and donations to the Medical Society’s charitable
foundation and just completed its third and final year of funding under the Community
Access Program (CAP) from the U.S. Department of Health and Human Services. In
addition, Dallas County recently approved a $125,000 contribution to help support
growing pharmacy costs in the program.
Project Access – Summary 2001 - 2004

Performance Measure Year 1 Year 2 Year 3* Year 4**
Unduplicated patients 62 475 971 1,463
Prescriptions filled 143 1,954 5,480 6,156
Average prescription cost $35.81 $33.71 $27.08 $23.97
New physician appointments 48 370 568 626
Primary care physician appointments 9 321 503 555
Specialty care physician appointments 31 167 407 449
Hospital contacts 4 18 65 72
Ancillary/radiological contacts 10 92 273 301
Patients contacted by community health workers 612 1,825 4,812 5,307
Value of donated care $26,026 $307,096 $627,396 $945,098
Value of donated care per enrollee $420 $646 $646 $646
Average Monthly Enrollment 43 172 408 450
* Annualized 9 month Year 3 Average (Sept. 03-May 04)
** Estimates based on Year 3 Rate/Enrollee/Mo.
Federally Qualified Health Centers (FQHC)
There are two Federally Qualified Health Centers (FQHCs) located in Dallas County.
FQHCs are required to provide care to all individuals regardless of ability to pay in
exchange for receiving cash-based reimbursement from Medicare and Medicaid and
access to other federal grants and programs. FQHCs are governed by community boards.
MLK Family Center

2922-B Martin Luther King Jr. Blvd.
Dallas, TX 75215
The Martin Luther King Jr. Family Center is located in the Fair Park area of Dallas and
provides primary care and dental care to the underserved of Dallas. In 2002, the clinic
saw more than 20,000 patients and provided immunizations for 8,000 children. The clinic
has three physicians, two dentists and two nurse practitioners and sees an average of 200
patients per day.
Health Management Associates Appendix D

Martin Luther King has an in-house laboratory and pharmacy and also provides
transportation services to appointments for patients who do not have access to their own
transportation.
Los Barrios Unidos

809 Singleton Blvd.
Dallas, TX 75212
Los Barrios Unidos is located in the West Dallas neighborhood and has been operating
for thirty-two years. Los Barrios provides prenatal, well-baby, adolescent health,
immunizations, dental for children 5 to 17, some x-rays, pharmacy, some optometry,
adult and geriatric services, WIC and other services. Each year, Los Barrios provides
60,000 medical encounters and an additional 40,000 other clinical encounters. Twelve to
15 percent of the clinics patients have Medicaid; the rest are self-pay.
Los Barrios has 7 FTE pediatricians, 7 FTE internal medicine physicians, 6 FTE ob/gyns
affiliated with Methodist Hospital, 2 nurse practitioners devoted to prenatal care, and 1
FTE dentist. The clinic sees 1,500 obstetrical patients each year. Approximately half of
these women deliver at Parkland Hospital, while most of the remaining deliver at
Methodist.
Dallas County Free Clinics
A number of free primary and urgent care clinics operate within Dallas County to help
meet the needs of the uninsured. Many are sponsored by faith-based groups and most
have limited hours and volunteer providers. Following is a list of the Dallas County
clinics that participate in the Dallas County Medical Society Health Clinics Forum,
including 2003 visits, where available (note: this is not an inclusive list of all clinics in
Dallas County that provide free or low-cost care).
Dallas County Medical Society Health Clinics Forum

Clinic 2003 Visits
Agape Clinic at Grace United Methodist Church 7,722
Central Dallas Ministries Community Health Services 3,753
Christ’s Family Clinic
Christian Community Action Adult Health Center
Cornerstone Ministries Life Medical Clinic
Dallas Life Foundation 5,426
Friendship House Health Ministries 560 (2002 visits)
Grand Prarie Wellness Center 2,020
Islamic Association of North Texas Clinic
Metrocrest Family Medical Clinic
Mission East Dallas 1,286 (medical and dental)
North Dallas Shared Ministries Medical Clinic 3,400
North Texas Indian Physicians Charitable Clinic
The Stewpot Clinic 1,881
Urban Inter-Tribal Center of Texas
*Source: Dallas County Medical Society and Parkland Strategic Planning & Population Medicine

Dallas County Department of Health and Human Services
In 2002, the Dallas County Department of Health and Human Services expended
approximately $7.2 million of general fund dollars to health administration, public health
and disease prevention efforts and administered an additional $4.3 million in grant
funding for disease prevention, training and immunization efforts. The following table
summarizes utilization of the department’s immunization and clinic services over the last
three years.
Indicator FY 2001 FY 2002 FY 2003

Childhood Immunizations 54,703 43,582 47,711
STD Clinic Visits 18,147 17,189 15,948
TB Clinic Visits 53,230 58,742 53,684
Source: Dallas County Management Report
Dallas Department of Environmental and Health Services.
The city of Dallas spent slightly more than $5 million on low-income health care services
in 2002. The majority of this spending came from the city’s general fund to finance
neighborhood clinics providing health screening and immunization services. The city also
received about $725,000 in grant funding from the Texas Department of Health (TDH)
for disease screening, immunization and lead abatement initiatives. The Dallas
Department of Environmental and Health Services provides approximately 5,000 office
visits for children at its four neighborhood clinics, approximately 1,000 visits to its low
birth weight clinic, and provides 150,000 immunizations each year.

Parkland Health & Hospital
System Uncompensated &
Undocumented Health Care
Analysis
Prepared for
October 7, 2004
1310 South First St. #105

Austin, Texas 78704
512-328-8300
www.txp.com
Parkland Uncompensated & Undocumented Health Care Analysis
Table of Contents
Introduction ...................................................................................................................................1
1. Assess Parkland’s Role in the Dallas Regional Economy ....................................................1
2. Identify the Current Level of Uncompensated and Undocumented Care ............................2
3. Analyze and Forecast Tax Revenues Used to Fund Uncompensated Care ......................10
4. Determine the Drivers of Parkland Uncompensated Care ..................................................12
5. Develop a 10-year Forecast for Parkland Uncompensated Health Care Costs .................15
Introduction
In light of shifting patterns of demand and changing demographics, an assessment was
undertaken to analyze the key factors affecting the Parkland Health & Hospital System’s
(Parkland) future uncompensated care costs. Five tasks were required for this analysis: 1)
Assess Parkland’s Role in the Dallas Regional Economy; 2) Identify the Current Level of
Uncompensated and Undocumented Care for the Dallas Region; 3) Analyze and Forecast Tax
Revenues Used to Fund Uncompensated Care; 4) Determine the Drivers of Parkland
Uncompensated Care; and 5) Develop a 10-year Forecast for Parkland Uncompensated Health
Care.
1. Assess Parkland’s Role in the Dallas Regional Economy

As a starting point for this analysis, it is important to understand Parkland’s role in the overall
Dallas MSA. Public hospitals typically attract a disproportionately larger share of regional
uncompensated health care, commensurately lowering the amount of uncompensated care
provided by private hospitals. Since less uncompensated care is provided, private hospitals may
be able to charge lower fees for overall health services. Beyond this “cost-containment” function,
access to high quality public health care is crucial to the general well-being of a region for a
number of additional reasons. First, health care is an oftentimes listed as a critical “site selection
factor” for expanding and relocating businesses. Even if a business offers private heath
insurance, the quality and existence of a public medical institution servers as an indicator of the
region’s overall health care infrastructure. Second, a hospital’s affiliation with a medical school
increases the region’s ability to attract doctors, nurses, and other medical support staff as well as
creating an environment that can lead to spin-off economic developments. Third, hospitals are an
important driver of economic activity in a region. Medical institutions typically pay above average
wages, employ a large number of workers, and partake in a significant level of R&D.
Annual Economic Impact of Parkland

In 2003, Parkland employed approximately 7,800 part and full-time workers and paid salaries and
benefits in excess of $410.5 million. The benefits of Parkland to the entire Dallas MSA economy
consist of the day-to-day operation of the hospital, normal operating expenditures, purchases
from local vendors, and spending of people employed by these businesses. In the final analysis,
the economic benefits of this spending materialize in the form of increased Dallas MSA
employment and income. The annual economic impact of Parkland has been calculated based
on 2003 wage, salary, and total hospital charges. Specifically, this section of the analysis
measures the economic impacts of Parkland’s normal operating activity on the Dallas MSA.
Economic Impact Methodology

In an input-output analysis of new economic activity, it is useful to distinguish three types of
expenditure effects: Direct, Indirect, and Induced.
Direct effects are production changes associated with the immediate effects or final demand
changes. The payment made by an out-of-town visitor to a hotel operator is an example of a
direct effect, as would be the taxi fare that visitor paid to be transported into town from the airport.
Indirect effects are production changes in backward-linked industries caused by the changing
input needs of directly affected industries – typically, additional purchases to produce additional
output. Satisfying the demand for an overnight stay will require the hotel operator to purchase
additional cleaning supplies and services, for example, and the taxi driver will have to replace the
gasoline consumed during the trip from the airport. These downstream purchases affect the
economic status of other local merchants and workers.
Page - 1 -
Induced effects are the changes in regional household spending patterns caused by changes in
household income generated from the direct and indirect effects. Both the hotel operator and taxi
driver experience increased income from the visitor’s stay, for example, as do the cleaning
supplies outlet and the gas station proprietor. Induced effects capture the way in which this
increased income is in turn spent by these people in the local economy.
Figure 1: The Effects of an Initial Change in Economic Activity
Direct Indirect Induced Total Impact

+ + =
An economy can be measured in a number of ways. Three of the most common are “Output,”
which describes total economic activity, and is equivalent to a firm’s gross sales; “Value Added,”
which equals payments made by industry to workers, interest, profits, and indirect business taxes;
and “Employment,” which refers to full and part-time jobs that have been created in the local
economy. In order to provide an accurate basis of comparison, all dollar-denominated results are
expressed in constant 2003 figures.
The interdependence between different sectors of the economy is reflected in the concept of a
“multiplier.” An output multiplier, for example, divides the total (direct, indirect and induced)
effects of an initial spending injection by the value of that injection – i.e., the direct effect. The
higher the multiplier, the greater the interdependence among different sectors of the economy.
An output multiplier of 1.4, for example, means that for every $1,000 injected into the economy,
another $400 in output is produced in all sectors.
Annual Economic Impact of Parkland’s Normal Operating Activity

On the Dallas Metropolitan Statistical Area Economy
Output Labor Income Employment
(millions) (millions) (Part & Full-time)
Direct $709.1* $410.5 7,810
Indirect & Induced $581.5 $225.1 5,393
Total $1,290.6 $635.6 13,203
Source: TXP
* Parkland Health & Hospital System FY2003 Payments & Allocations
The value of Parkland’s annual economic activity to the region is clear. The hospital system’s
direct operations will generate an annual increase of $1.3 billion in total output, $635.6 million in
employee wages, while supporting a total of 13,200 full and part-time local jobs.
2. Identify the Current Level of Uncompensated and Undocumented Care

As Dallas County’s only public and tax-supported hospital, Parkland is the leading provider of
uncompensated care for the community. In 2002, Parkland provided over $410 million in
uncompensated care (charges based on charity care and bad debt). This represents nearly 50
percent of all uncompensated care provided by Dallas County acute care hospitals. From 1998-
2002, Parkland’s total uncompensated care charges increased 33 percent or a compound annual
growth rate of 7.3 percent.
Page - 2 -
Parkland Hospital Uncompensated Care Charges

1995 - 2002
$500
$400.7 $410.1
$400
$353.4 $358.5 $351.6
$300.6 $301.5
$290.0
$300
(Millions)
$200
$100
$0
1995 1996 1997 1998 1999 2000 2001 2002
Source: Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database
Dallas MSA Uncompensated Care Charges

1995 - 2002
$1,200
Dallas MSA
Dallas County
$1,000 Parkland
$800
(Millions)
$600
$400
$200
$0
1995 1996 1997 1998 1999 2000 2001 2002
Source: Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database
Page - 3 -
The Parkland HEALTHplus program is the mechanism used to meet a significant portion of the
medical needs of Dallas County’s low income citizens. The following highlights of the Parkland
HEALTHplus program was obtained from the Annual Report of Charity and Community Benefits
for Fiscal Year 2001 And Plans for Fiscal Year 2002:
Parkland HEALTHplus is designed to meet the health care needs of the medically and
financially needy residents of Dallas County. Because of their inability to pay, many lower-
income Americans have had limited, and in many cases, no access to arguably the finest
medical care the world has to offer. Parkland HEALTHplus focuses on preventive health
care in Dallas County through more than a dozen of its neighborhood and school-based
health centers.
Parkland HEALTHplus is a sliding scale payment program for Dallas County self pay
patients. This program is designed to foster increased patient responsibility while
providing access to and continuity of care. The bottom line for Parkland; better allocation
of health care resources, allows Parkland to provide more patients with quality care for the
same health care dollar.
Parkland HEALTHplus also serves as a crossover program for patients no longer eligible
for Medicaid. Many residents of Dallas County, while earning too much money to qualify
for Medicaid, still cannot afford traditional health care coverage. Rather than let this
population continue to go unserved, Parkland HEALTHplus will allow them access to
quality health care, at a cost determined on a sliding income scale.
Page - 4 -
Parkland HEALTHplus Encounters

2001 - 2003
500,000
Inpatients
Outpatients 413,555
400,000 372,878
354,293
300,000
200,000
100,000
3,721 3,712 4,009

0
2001 2002 2003
Source: Parkland Health & Hospital System
Parkland HEALTHplus Charges

2001 - 2003
$200
Inpatients
Outpatients
$150
$126.8
$117.8
(Millions)
$100 $94.8
$64.9
$52.2 $49.5
$50
$0
2001 2002 2003
Page - 5 -
Parkland HEALTHplus Costs

2001 - 2003
$200
Inpatients
Outpatients
$150
(Millions)
$100 $89.8
$76.1 $78.5
$50
$31.1 $34.5
$29.4
$0
2001 2002 2003
Parkland HEALTHplus Encounters by Sliding Scale Category

2001 - 2003
500,000
Parkland HEALTHPlus Level 2
All Other
400,000
312,390 303,925
300,000 280,388
200,000
104,877
100,000 77,626 72,962
0
2001 2002 2003
Page - 6 -
Parkland HEALTHplus Charges by Sliding Scale Category

2001 - 2003
$200
All Other $156.8

$150
$135.2
$118.2
(Millions)
$100
$50
$32.1 $34.9
$28.8
$0
2001 2002 2003
Parkland HEALTHplus Costs by Sliding Scale Category

2001 - 2003
$200
All Other
$150
(Millions)
$96.7 $92.6
$100
$83.9
$50
$21.5 $24.1 $20.4
$0
2001 2002 2003
Page - 7 -
A review of Parkland HEALTHplus activities over the past three years reveal a number of
important considerations that influenced the forecasting of total Parkland uncompensated care:
• Based on historical data provided by the Texas Department of Health and information
provided by Parkland on the HEALTHplus program, the HEALTHplus program
represents 40-50 percent of total Parkland uncompensated care charges.
• From 2001-2003, 78 percent of HEALTHplus patients were eligible to receive services

under the Level 2 category. To qualify for Level 2 coverage, the Dallas County
resident must have income less than 133 percent of the federal poverty level and have
no other primary coverage (i.e., Medicare, Medicaid, or commercial insurance).
• The sliding scale used for the HEALTHplus program is divided into three main
categories and is based on income relative to the federal poverty level (FPL) and
family size: 0-133 percent of FPL, 133-200 percent of FPL, and 200-250 percent of
FPL. Given the overwhelming utilization of the HEALTHplus by residents in the 0-133
percent of FPL bracket, most attempts to reduce costs would be minimal unless
changes were made to this category.
• The cost-to-charge ratio for the HEALTHplus program during fiscal year 2003 was 59
percent. This is down significantly from the 72 percent cost-to-charge ratio
experienced in fiscal years 2001 and 2002. The change in the cost-to-charge ratio
was a result of Parkland’s response to Medicaid reimbursement rules that provide
funding based on hospital charges. By increasing the charges for uncompensated
care, Parkland was able to receive additional federal funds. This policy change had
the indirect effect of lowering the cost-to-charge ratio.
• The cost-to-charge ratio for the entire Parkland system was 46 percent for fiscal year
2003. This is below the 1999-2002 cost-to-charge ratio of 54 percent.
Uncompensated care provided by Parkland is not limited to the HEALTHplus program and
medical treatment for undocumented residents. Parkland also provides the community free and
reduced services through unreimbursed costs of subsidized health services, educational
programs, and unreimbursed research costs. In addition, health care provided to patients who do
not qualify for the Healthplus program and/or do not have the ability to pay is also defined as
uncompensated care. These other uncompensated costs represent approximately 50 percent of
total Parkland annual uncompensated care charges.
As part of this analysis, it is also important to understand the level of care provided to
undocumented residents. While most hospitals, including Parkland, do not verify legal status
prior to emergency room treatment, many states along the U.S.-Mexico border are experiencing
financial burdens in providing this care. A recent study by MGT of America, Medical Emergency:
Costs of Uncompensated Care in Southwest Border Counties, identifies the challenges in
providing care to undocumented persons1:
• The Emergency Medical and Treatment and Active Labor Act (EMTALA) requires
hospitals and emergency personnel to screen, treat and stabilize anyone who seeks
emergency medical care regardless of income or immigration status. Under
1
TXP served as subcontractors to MGT on this study, with Jon Hockenyos and Chandler Stolp of TXP responsible for
developing the estimating methodology that produced these figures.
Page - 8 -
Emergency Medicaid, the federal government pays for some emergency medical care
delivered to undocumented immigrants who, except for their immigration status, would
be eligible for Medicaid. EMTALA mandates conflict with Emergency Medicaid
reimbursement policies to the extent that EMTALA requires screening and treatment
beyond those covered under the Medicaid “emergency condition” definition.
• No standard method to track the amount of uncompensated care provided to

undocumented immigrants currently exists. The absence of Social Security Numbers
(SSN), in combination with other factors, may provide the federal government with an
adequate proxy to enable tracking of aggregate amounts of uncompensated
emergency care delivered to undocumented immigrants.
• State and local governments and local health care providers absorb a large portion of
the costs of providing uncompensated emergency medical care to undocumented
immigrants. These costs impose a significant financial burden on southwest border
hospitals’ and emergency medical services (EMS) providers, and account for an
estimated 23 percent of hospitals uncompensated costs.
While Dallas County is not located on the Texas-Mexico border, anecdotal evidence from a
central Texas hospital that is currently tracking undocumented health care confirms these findings
would also apply to non-border counties. For the purposes of this study, it is estimated that
approximately 20 percent of uncompensated Parkland health care is provided to undocumented
persons (emergency and non-emergency treatment), a figure consistent with the MGT study and
the additional reported estimates in the region. This percentage is likely to remain fairly static
over the next ten years, as there are a number of countervailing forces at work. For example, the
ongoing overall disparity between the Mexican and U.S. economies suggests that the U.S. will
continue to be viewed as the land of economic opportunity, especially in light of domestic trends
such as greater female labor force participation, a shortage of blue-collar workers in the trades,
and the general aging of the population. All of these factors would suggest greater in-migration.
On the other hand, Border security has been heightened in the wake of 9/11 (both in terms of
policy and enforcement), which will tend to dampen movement of undocumented persons
northward. As a result, the percentage of uncompensated care attributable to undocumented
persons is held constant over the forecast horizon.
Page - 9 -
Estimated Parkland Uncompensated Care: U.S. and Undocumented Persons

1995 - 2002
$500
U.S. Citizens
Undocumented
$400
$300
(Millions)
$200
$100
$0
1995 1996 1997 1998 1999 2000 2001 2002
Source: TXP, Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database
3. Analyze and Forecast Tax Revenues Used to Fund Uncompensated Care

To help offset these uncompensated health care costs, Parkland receives public funds from the
Dallas County Hospital District. Note, the ad valorem tax rate increased from $0.196 per $100
valuation in 1999 to $0.254 per $100 valuation in 2000. To assess the long-term implications of
uncompensated care, a 10-year forecast of Dallas County Hospital District tax revenue was
created by extrapolating recent growth trends in the total appraised value of the District’s tax
base. After peaking at 9.1 percent growth during 1999, the value of the District’s tax base grew
only 0.2 percent during 2003 before rebounding to a 4.1 percent growth rate this year. A four-
year moving-average of annual growth was used to project the value of the tax base through
2015. By using a fairly short-term extrapolation base, greater emphasis is put on recent
performance, which is consistent with expectations that overall economic growth in the Dallas
area will be slower over the forecast horizon that it was during 1994-2004. As a result, the
District’s tax base is expected to grow at a compound annual rate of 3.1 percent for the next ten
years, in contrast to the 5.7 compound annual rate for the past ten.
Page - 10 -
Estimated Parkland Hospital District Tax Revenue

1995 - 2002
$400
$300
(Millions)
$200
$100
$0
1995 1996 1997 1998 1999 2000 2001 2002
Source: Dallas Central Appraisal District
Parkland Hospital District Tax Revenue Forecast

1995 - 2015
$600
Start of forecast values

$500
$400
(Millions)
$300
$200
$100
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP, Dallas Central Appraisal District
Page - 11 -
4. Determine the Drivers of Parkland Uncompensated Care
The fluctuation in uncompensated health care costs for Dallas County and Parkland is consistent
with the economic highs and lows witnessed over the past five years. The Dallas MSA was
disproportionately impacted by the downturn in the technology sector. Tens of thousands of high
paying jobs that provided health insurance were lost. Part of the explanation also lies in the
“jobless” nature of the current recovery – without significantly higher levels of job creation, it will
be challenging for many citizens to afford individual health insurance, private physician care, and
hospital health care costs. The demand for public sector health care services is largely a function
of access to private health insurance. As a result, changes in local economic activity, overall
employment, and benefits provided by local business to a large extent determine changes in
demand for public health care. This relationship is especially true over an extended period of
time.
There are two broad approaches to time series forecasting: extrapolation techniques, which use
past observations of a given series to predict its future values, and structural or econometric
methods, where changes in an explanatory variable or variables are used to forecast the series in
question. Each has its relative strengths. Extrapolation methods are normally considered to be
most effective when the number of observations in the series is high (ideally at least twenty),
when any underlying trends are fairly evident, and when the forecast horizon is short (usually no
more than six periods). In terms of uncompensated health care forecasting, actual elapsed time is
also relevant; using extrapolation techniques to forecast annual data is generally only appropriate
when the time series is “stationary,” which means it tends to revert to a constant long-term value.
Since measures of the economy (and, by extension, uncompensated health care) are not
stationary, extrapolation techniques, on a stand-alone basis, ideally should be used for very
short-term forecasts.
As mentioned above, structural forecasts involve using changes in an explanatory variable or

variables to forecast change in the series under analysis. Uncompensated health care costs are
generally highly correlated with changes in the overall economy, and, in particular, tend to reflect
shifts in personal income, access to employer sponsored health insurance, and overall regional
population and employment growth. In other words, uncompensated health care costs are based
on a combination of regional forces that may appear to be unrelated.
Ideally, an uncompensated health care cost equation would include all of the elements listed
above. However, limitations on data availability and timeliness make that approach less than
optimal at the local level. There is no credible Dallas-specific data on health insurance costs, and
information on undocumented residents is Dallas County is either not publicly available or does
not provide enough data points for analysis. As a result, alternative measures are used.
Dallas MSA and Parkland Per Capita Uncompensated Care Costs – Regression Model
Located in a major metropolitan area, Parkland is greatly influenced by regional economic trends,
which in turn are determined by national and international factors. Iterative regression modeling
suggests that regional employment data provides insight into the percentage of residents that
may have employer sponsored medical insurance (the Dallas County unemployment rate),
statistics on the percentage of non-U.S. residents without health insurance, and state data on
health insurance costs do an excellent job of explaining changes in Dallas MSA uncompensated
per capita health care costs. This data is then integrated with three alternative regional
population forecast scenarios (the driver determining the theoretical number of residents that may
need to be served) to generate overall levels of projected uncompensated care. The following
graphics depict data used in the regression model.
Page - 12 -
Percentage of Uninsured Non-Citizens Residing in the U.S.

1996 - 2002
80%
60%
42.4% 43.6% 42.9% 42.1% 42.9% 43.3%

41.7%
40%
20%
0%
1996 1997 1998 1999 2000 2001 2002
Source: TXP, U.S. Census Bureau
Texas Average Total Family Premium Per Enrolled Employee at Private-Sector

Establishments that Offer Health Insurance
1996 - 2002
$10,000
$8,837
$8,000 $7,486
$6,638
$6,209
$6,000 $5,693 $5,588
$4,899
$4,000
$2,000
$0
1996 1997 1998 1999 2000 2001 2002
Source: Medical Expenditure Panel Survey
Page - 13 -
Dallas County Unemployment Rate

1996 - 2002
10%
9%
8.0%
8%
7%
6% 5.4%
5% 4.5%
4.2%
4% 3.7% 3.5% 3.5%
3%
2%
1%
0%
1996 1997 1998 1999 2000 2001 2002
Source: Texas Workforce Commission
The end result of the first regression analysis was the identification of per capita cost of
uncompensated health care for the entire Dallas MSA. The logic is that the dynamic nature of the
Dallas MSA creates linkages between each county, with some non-Dallas County citizens
traveling to Parkland to receive medical treatment. Therefore, it is important that the model take
this interaction into account. An analysis limited to Dallas County or Parkland would fail to
capture these important components. The findings indicate that the equation is statistically
significant at the highest confidence level, with 95.5 percent of the change in uncompensated
health care costs being explained by changes in the independent variables. The following table
presents the results of the regression.
Table 1: Summary Regression Statistics

R Square Adjusted R Square Standard Error F – Statistic
.9550 .9099 8.7316 21.2091
Source: TXP
Once the explanatory relationship between per capita uncompensated health care costs and the
independent variables is delineated, actual values and projections of each variable can be used
to generate a specific forecast of Parkland uncompensated health care over the next ten years.
The projection for each of explanatory variable was based on 3rd order polynomial trend
extension, a process that yielded overall results reasonably consistent with extrapolation of the
dependent variable (per capita uncompensated care) itself.
Page - 14 -
Dallas MSA Per Capita Uncompensated Health Care Costs Forecast

1995-2015
$800
$600
$400
$200
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP
5. Develop a 10-year Forecast for Parkland Uncompensated Health Care Costs

Upon completion of developing the projections, Dallas County and Parkland’s share of regional
uncompensated health care costs were estimated based on the widely accepted county
population forecasts produced by the Texas State Data Center. Three population forecasts were
used to create low, medium, and high scenarios:
Low - The One-Half 1990-2000 Migration (0.5) Scenario - This scenario has been prepared as
an approximate average of the zero (0.0) and 1990-2000 (1.0) scenarios. It assumes rates of
net migration one-half of those of the 1990s. The reason for including this scenario is that many
counties in the State are unlikely to continue to experience the overall levels of relative
extensive growth of the 1990s. A scenario which projects rates of population growth that are
approximately an average of the zero and the 1990-2000 scenarios is one that suggests slower
than 1990-2000 but steady growth.
Medium - The 1990-2000 Migration (1.0) Scenario - The 1990-2000 scenario assumes that the
trends in the age, sex and race/ethnicity net migration rates of the 1990s will characterize those
occurring in the future of Texas. The 1990s was a period characterized by rapid growth. It is
seen here as the high growth alternative because its overall total decade pattern is one of
substantial growth (i.e., 22.8 percent for the 1990-2000 decade for the State). Because growth
was so extensive during the 1990s it is likely to be unsustainable over time and thus this
scenario is presented here as a high growth alternative. For counties that experienced net
outmigration during the 1990s, this scenario produces continued decline.
Page - 15 -
High - The 2000-2002 Migration Scenario - The 2000-2002 projection scenario provides a
scenario that takes into account post-2000 population trends. In the State overall and in some
counties the post-2000 period has resulted in reduced levels of net migration. In other counties
post-2000 net migration rates have been greater than those of the 1990s. Under this scenario
the 2000-2002 age, sex and race/ethnicity specific migration rates are assumed to prevail from
2000 through 2040. This scenario allows those users who believe that the 2000-2002 period
has produced fundamental long-term changes in population patterns to ascertain the likely
future size and characteristics of the population.
Dallas Metropolitan Statistical Area Population Forecast

1995-2005
6.0
Low
5.5
Medium
5.0 High
(Millions)
4.5
4.0
3.5
3.0
2.5
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: Texas State Data Center
The result of Task 2 yielded a per capita uncompensated health care cost for the Dallas MSA.
The following graphics depict the uncompensated health care cost scenarios based on varying
levels of population growth. The cost-to-charge ratio used was 55 percent, consistent with the
cost-to-charge ratio for Parkland over the past few years. Projected Parkland Hospital District tax
revenue estimates have been incorporated into the charts to highlight potential shortfalls in
revenue and assist in long-term planning.
Medicaid Reimbursement Shortfall and Other Parkland Uncompensated Costs

The uncompensated costs scenarios do not include any shortfall due to insufficient Medicaid
reimbursement or other hospital losses offset by Parkland Hospital District tax revenues. In 2003,
for example, Parkland experienced a Medicaid shortfall of $63.4 million. Since Medicaid
reimbursement rates can fluctuate substantially over time and are determined by public policy at
the national level, these costs have been excluded. Therefore, any graphic or data that depicts
Parkland tax revenues in excess of uncompensated costs does not assume these funds are not
required to support and sustain other important hospital operations and activities.
Page - 16 -
Parkland Uncompensated Costs Scenarios

1995 - 2015
$800
Low Start of forecast values
Medium
$600 High
(Millions)
$400
$200
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP
Parkland Uncompensated Costs

Low Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue
Uncompensated Costs
$600
(Millions)
$400
$200
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP
Page - 17 -

Medium Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue
Uncompensated Costs
$600
(Millions)
$400
$200
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP

High Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue
Uncompensated Costs
$600
(Millions)
$400
$200
$0
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Source: TXP
Page - 18 -
Dallas MSA Population Estimates & Per Capita Uncompensated Charges
1995 - 2015
Dallas MSA Population Dallas County Population Est. Charges
Year Low Medium High Low Medium High Per Capita (MSA)
1995 2,958,809 2,958,809 2,958,809 1,961,007 1,961,007 1,961,007 $194
1996 3,032,906 3,032,906 3,032,906 1,986,996 1,986,996 1,986,996 $211
1997 3,117,245 3,117,245 3,117,245 2,016,929 2,016,929 2,016,929 $217
1998 3,202,721 3,202,721 3,202,721 2,045,309 2,045,309 2,045,309 $235
1999 3,280,310 3,280,310 3,280,310 2,062,100 2,062,100 2,062,100 $257
2000 3,519,176 3,519,176 3,519,176 2,218,899 2,218,899 2,218,899 $255
2001 3,560,750 3,592,060 3,611,665 2,245,639 2,251,775 2,257,306 $267
2002 3,602,766 3,667,611 3,709,756 2,270,794 2,284,143 2,298,091 $294
2003 3,642,929 3,743,993 3,812,413 2,296,507 2,318,646 2,341,937 $308
2004 3,681,986 3,820,773 3,918,475 2,321,572 2,352,877 2,387,537 $326
2005 3,719,867 3,898,970 4,028,336 2,346,180 2,388,186 2,434,946 $345
2006 3,755,989 3,977,406 4,142,271 2,369,565 2,423,428 2,484,686 $365
2007 3,790,439 4,056,798 4,259,042 2,391,945 2,459,162 2,535,923 $386
2008 3,823,287 4,135,858 4,380,320 2,413,366 2,494,168 2,589,165 $407
2009 3,854,937 4,215,645 4,504,945 2,433,817 2,529,553 2,644,450 $428
2010 3,885,472 4,296,902 4,633,516 2,453,675 2,565,731 2,702,237 $450
2011 3,915,001 4,377,878 4,766,790 2,472,908 2,601,214 2,762,094 $472
2012 3,943,221 4,460,569 4,904,636 2,491,295 2,638,001 2,824,527 $494
2013 3,970,770 4,544,027 5,046,817 2,509,214 2,674,973 2,889,021 $515
2014 3,996,917 4,628,444 5,194,257 2,526,262 2,712,368 2,956,289 $537
2015 4,022,783 4,713,133 5,345,840 2,542,977 2,749,375 3,025,283 $558
Source: U.S. Census Bureau, Texas State Data Center, TXP
Parkland Uncompensated Charge & Cost Estimates

1995 - 2015
Charges (Millions) Cost (Millions) Estimated
Year Low Medium High Low Medium High Tax Revenue
1995 $290.0 $290.0 $290.0 $159.5 $159.5 $159.5 $159.6
1996 $300.6 $300.6 $300.6 $165.3 $165.3 $165.3 $162.9
1997 $301.5 $301.5 $301.5 $165.8 $165.8 $165.8 $167.6
1998 $353.4 $353.4 $353.4 $194.4 $194.4 $194.4 $176.8
1999 $400.7 $400.7 $400.7 $220.4 $220.4 $220.4 $210.1
2000 $358.5 $358.5 $358.5 $197.2 $197.2 $197.2 $292.8
2001 $351.6 $351.6 $351.6 $193.4 $193.4 $193.4 $317.6
2002 $410.1 $410.1 $410.1 $225.5 $225.5 $225.5 $327.4
2003 $432.4 $444.4 $452.5 $237.8 $244.4 $248.9 $328.0
2004 $457.3 $474.6 $486.7 $251.5 $261.0 $267.7 $341.4
2005 $494.1 $517.9 $535.0 $271.7 $284.8 $294.3 $354.9
2006 $526.4 $557.5 $580.6 $289.5 $306.6 $319.3 $364.9
2007 $560.2 $599.6 $629.5 $308.1 $329.8 $346.2 $375.0
2008 $597.0 $645.8 $684.0 $328.4 $355.2 $376.2 $387.8
2009 $633.2 $692.4 $740.0 $348.3 $380.8 $407.0 $400.3
2010 $670.4 $741.4 $799.5 $368.7 $407.8 $439.7 $412.6
2011 $708.5 $792.3 $862.7 $389.7 $435.7 $474.5 $425.5
2012 $746.5 $844.5 $928.5 $410.6 $464.5 $510.7 $439.1
2013 $784.9 $898.2 $997.6 $431.7 $494.0 $548.7 $452.9
2014 $823.1 $953.2 $1,069.7 $452.7 $524.2 $588.3 $467.1
2015 $861.2 $1,008.9 $1,144.4 $473.6 $554.9 $629.4 $481.9
Source: TXP
Page - 19 -
Legal Disclaimer
Every attempt has been made to ensure the information contained herein is valid at the
time of publication. Texas Perspectives Inc. (TXP), however, reserves the right to make
changes, corrections and/or improvements at any time and without notice. In addition,
Texas Perspectives Inc. disclaims any and all liability for damages incurred directly or
indirectly as a result of errors, omissions or discrepancies.
Any statements involving matters of opinion or estimates, whether or not so expressly

stated, are set forth as such and not as representations of fact, and no representation
is made that such opinions or estimates will be realized. The information and
expressions of opinion contained herein are subject to change without notice, and shall
not, under any circumstances, create any implications that there has been no change
or updates.
Page - 20 -
Medicaid Reimbursement Comparisons
The following table presents a comparison of Medicaid payments to large public

hospitals on an adjusted Medicaid patient day basis. It is important to note that hospitals
report their Medicaid payments differently. The payments in the table include base
Medicaid payments, net DSH payments and, in some cases, net UPL payments. Because
of differences in reporting, these figures are not exact, but they do illustrate the
magnitude of the Medicaid reimbursement issue at Parkland.
Medicaid Payment Comparison -- Selected Hospitals (2002)
Estimated Medicaid
Payments/ Adjusted
Estimated Adjusted Medicaid Patient
Hospital Medicaid Patient Days Medicaid Payments Day
Parkland 196,593 $214,434,922 $1,091
Jackson Memorial 133,133 $276,035,801 $2,073
Cook County 103,588 $229,648,946 $2,217
Wishard 70,140 $170,859,154 $2,436
LA County – USC 164,974 $440,755,042 $2,672
Denver Health 41,525 $164,279,991 $3,956
Total/Average 709,953 $1,496,013,856 $2,107
Source: NAPH 2002 Member Survey
Health Management Associates Appendix F

Parkland Pharmacy Issue Paper
I. Pharmacy Overview
Parkland pharmacy represents approximately $80 million of Parkland’s overall $820 million
budget (FY05 budget request). Approximately 300 staff including pharmacists, pharmacist
technicians, and support staff cover operations for all campus and off-campus locations. Some
observations about Parkland’s pharmacy program:
• Systems and Automation Capacity Appear to be Progressive – automated ambulatory
prescription filling at all clinics, PPC, and OPC, access to patient profiles on the intranet
for prescribing physicians and pharmacists, and the T2 cost accounting system appear to
provide a strong system infrastructure.
• Pharmacy and Therapeutics Committee and Preferred Drug List Appear to be
Aggressive. Parkland works closely with Southwestern physicians and COPC physicians
to coordinate the P&T’s Committee work. Looking at access in some of the highly
prescribed classes indicates that the PDL is being carefully managed (e.g. 1 statin and 1
SSRI on the PDL). 99% of prescriptions filled are filled from the PDL.
• Drug Manufacturer Supplemental Rebates and Product Donation Appear to be
Aggressive –Additional rebates from drug manufacturers and product donation are one
variables taken into consideration (in addition to patient safety, efficacy) as the preferred
drug list is constructed. Parkland obtained $22.7 million in product through the Texas
Department of Health, various drug manufacturers, and investigational drug services.
II. Opportunities under MMA

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
provides several opportunities for safety net providers like Parkland. Members that currently
receive drugs through PHP will either access their medications at Parkland or off site at a local
pharmacy. Either scenario benefits Parkland in terms of reduced exposure to a cost pressure.
• Drug Discount Subsidies – From June, 2004 through December 2005, beneficiaries
below 135% of FPL ($12,569/single;$16,862/couple in 2004) who do not have private or
Medicaid drug coverage will have $600 per year for drug expenses. Parkland estimates
the target population (Medicare recipients not enrolled in Medicaid) to be approximately
4,900 individuals.
• Drug Discount Subsidies Impact - If 25% of the 4,900 eligibles are enrolled with a
discount drug card, this will save Parkland up to $1.1 million. The impact of the
subsidies could be as high as $5.9 million (through December 2005) depending upon
federal enrollment provisions, how the Discount Card will be integrated into PHP
eligibility, and how much of the subsidy is spent by the member. Every effort should be
made to coordinate PHP members and prospective members with the Drug Discount
Card.
• Low-Income Assistance – Medicare will provide additional assistance on January 1,
2006. Outpatient prescription drugs will be covered through private plans. Whereas the
majority of beneficiaries will have substantial cost sharing responsibilities:
o Beneficiaries with incomes below 135% of FPL will receive a subsidy to cover
the average premium cost and will have no deductible and no cost-sharing above
the out of pocket threshold. They will pay $2 and $5 copays.
Health Management Associates Appendix G

o Beneficiaries with incomes below 150% of FPL will receive premium subsides on
a sliding scale. They will pay a $50 deductible, 15% coinsurance up to the out of
pocket threshold, and $2 to $5 copays above the threshold.
• Low-Income Assistance Impact – The 4,900 individuals were responsible for
approximately $4.9 million for the past 4 quarters. Since the Low-Income population is
covered at slightly higher income levels than the Discount Card (150% FPL vs. 135%
FPL), a larger population will be covered. Given the limitations of the T2 and the
eligibility system, the 0%-150% cohort is prorated to be approximately 5,800 individuals
and $5.8 million. This is maximum estimated number. It is recommended that this be
looked into in greater detail considering MMA cost-sharing requirements and
participation rates.
• Enrollment in MMA is Voluntary and Seamless Coordination with PHP is
Imperative to Maximize MMA’s Value. It will be important to enroll as many PHP
members and prospective PHP members into a Medicare Drug Plan as possible. The
details associated with late enrollment are yet to be established by the Secretary of HHS,
but it is important to note that late enrollments may potentially adversely affect Parkland.
III. Capacity Issues

There will be several issues associated with the pharmacy cost and system capabilities over
time. The following data will lay out some of the key indicators that reflect some of the
compelling pharmacy issues:
Table 1:
2000 2001 2002 2003 2004
Number of Prescriptions 1,399,203 1,482,517 1,697,267 1,881,189 1,823,308
Mail Order Prescriptions 0 7,267 7,814 11,344 17,266
Refill Percentage 47% 51% 53% 50% 57%
Turn Around Time (min) 56 73 38 46 62
Source: Parkland Pharmacy, 2004
Chart 1:
Prescription Volume Over Time
(in millions)
2.0
1.5
Prescriptions
1.0
Refills
0.5
0.0
2000 2001 2002 2003 2004
Source: Parkland Pharmacy, 2004

Chart 2: Chart 3:
2004 Prescription Volume by Payor 2004 Prescriptions by Type
PHP Refills
30%
Non-indigent 43% New Presciptions
70%
57%
Source: Parkland Pharmacy, 2004 Source: Parkland Pharmacy, 2004

Department of Pharmacy Services
Annualized Pharmacy Statistics by Store Cost Center
COPC Facilities On Campus Facilities
deHaro - East Bluitt Southeast Discharge / OPC PPC Grand

Saldivar Dallas Garland Flowers Dallas ER Pharmacy Pharmacy Pharmacy Totals
Fiscal Year 2000
Total Rx Volume 94,817 92,687 83,515 142,111 139,114 217,369 315,277 314,313 1,399,203
Average Rx TAT (min) 19 75 25 54 75 23 109 68 56
Mail Order Rx's - - - - - - - - 0
Fiscal Year 2001

Total Rx Volume 118,043 108,308 99,699 147,783 152,159 204,276 289,008 363,241 1,482,517
Mail Order Rx's - - - - - - - 7,267 7,267
Fiscal Year 2002

Total Rx Volume 140,138 127,442 121,749 176,206 193,930 202,366 338,045 397,391 1,697,267
Mail Order Rx's - - - - - - - 7,814 7,814
Fiscal Year 2003

Total Rx Volume 167,091 152,477 123,872 192,710 233,929 196,685 363,835 450,590 1,881,189
Mail Order Rx's - - - - - - - 11,344 11,344
Fiscal Year 2004 *

Total Rx Volume 176,954 156,841 129,773 176,751 246,548 119,205 358,421 458,815 1,823,308
Mail Order Rx's - - - - - - 17,266 17,266
* Annualized based on 11 months YTD

Source: Parkland Pharmacy

Compelling Issues
• Opportunity for Mail Order Pharmacy is Strong – Infrastructure issues will need to
be addressed as drug volumes will increase over time. It is clear given the current mail
order volume, the current refill level (57%) that mail order pharmacy, a central refill
station, or a combination of the two are an important consideration when moving
forward. Substantial operational savings opportunities are available for the present and
opportunities to deal with outyear pricing and infrastructure pressures add layers of
options.
• Central Refill Station - If implemented as a package with mail order, there will be a
significant reduction in labor costs, increased patient safety and reduced turnaround
times. Implementing any part of the automation by itself will help, but it will not provide
the potential returns as package will.
• PHP Dominates Drug Use – PHP represented 70% of the prescription volume as
indicated in Chart 2. Opportunities for care management with PHP may pay dividends in
the pharmacy budget.
• Careful Monitoring of Prescription Volumes and Unintended Impacts – Parkland
changed its discharge policy which has had an effect upon prescription volume. Table 2
indicates that prescription volume is likely to decrease in 2004 for the first time in many
years. This is likely a combination of the discharge policy and stations at PPC and OPC
operating at full capacity. It will be important to monitor if a suppressed demands creates
unintended consequences at other points in the system
• Prescription Turn-Around Times – Turn-Around times for filling prescriptions
substantially increased from 2002 to 2004 (decrease from 01 to 02 was due to automation
adjustments and redesign). OPC and PPC are at capacity with waits over 2.5 hours while
clinic times remain relatively reasonable.

PARKLAND COMMUNITY HEALTH PLAN
KEY FINDINGS AND RECOMMENDATIONS
Isadore J. King, MBA, CPA
October 6, 2004
SCOPE
This review was limited to the Medicaid and CHIP HMO operations of Parkland
Community Health Plan (PCHP) and included an in depth interview with Timothy Bahe,
Executive Director. None of the findings and recommendations applies to the indigent
health plan or the employee health plan.
DOCUMENT REVIEW
The following documents were reviewed and serve as the basis for the contents of this
report.
A. PCHP Meeting Summary May 24, 2004

B. PCHP Board Overview February 11, 2004
C. PCHP Executive Summary April 2004
D. AETNA (NYLCare Southwest) ASO Contract
E. PCHP Board Orientation July 2004
KEY FINDINGS
• In 2003 PCHP generated a total loss of $4.0 million ($6.0 million loss for
Medicaid, $2.0 million profit for CHIP)
• For the first quarter of 2004 PCHP operated at breakeven (approximate $1.0
million loss for Medicaid, $1.0 million profit for CHIP)
• Medicaid revenue pmpm for first quarter of 2004 increased by 6% ($155.36 vs.
$146.91), medical costs increased slightly ($135.32 vs. $134.16) and
administrative costs increased by 19% ($23.59 vs. $19.84)
• Improved Medicaid results for first quarter of 2004 attributed to 9/03 Medicaid
rate increase and renegotiation of provider contracts to lower rates
• CHIP revenue pmpm for first quarter of 2004 was flat ($78.94 vs. $78.89),
medical costs decreased by 13% ($56.65 vs. $64.99) and administrative costs
increased by 54% ($11.96 vs. $7.79)
• AETNA ASO fees pmpm for both products increased by 2.5% (Medicaid $16.40
vs. 16.00, CHIP $8.95 vs. $8.73)
• Overall administrative costs are 15% for both products
• PCHP has acquired staffing and other resources to provide leadership, oversight,
direction and communications in the areas of Marketing, Community Relations,
1
Member Services, Provider Relations and Medical Management; AETNA
remains responsible for program implementation and day to day operations
• PCHP pays Children’s Medical Center 105% of Medicaid rates
• PCHP pays non-participating CHIP providers 100% of billed charges
• All PCPs are paid a $3 pmpm gatekeeping fee
• No detailed actuarial analysis has been conducted for Medicaid or CHIP revenue
rates
• AETNA provides comprehensive data files to PCHP but PCHP has to perform
extensive data analysis to obtain relevant, useful and actionable information
• Budgeting, financial and utilization reporting are performed at aggregate and
gross levels with limited ability to drill down to cost, quality and utilization
drivers or perform root cause analyses
• Data received from behavioral health and PBM providers (services are carved-
out) is not useful or actionable
• There is no provider profiling capability
RECOMMENDATIONS
• Reduce administrative costs to industry standard of 12 % of revenue; ASO

services and internal administrative operations should be reviewed to delineate
responsibilities, clarify deliverables, eliminate redundancies, and identify and take
advantage of any opportunities for synergy. We understand that the U.S.
Department of Health and Human Services Office of the Inspector General (OIG)
will be conducting an audit of the administrative costs of all Medicaid managed
care plans in the current fiscal year. PCHP’s current administrative cost structure
will not be viewed favorably in this review.
• Renegotiate ASO contract to provide for fee reductions at higher membership
levels
• Renegotiate provider contracts (as applicable) to pay Medicaid rates (especially
Children’s)
• Pay all CHIP non-participating providers at reasonable and customary rates
• Eliminate $3 gatekeeping fee for PCPs; establish an incentive pool (for ex: $1.0
million) to reward PCPs who achieve certain utilization and quality targets
• Conduct detailed actuarial analyses of Medicaid and CHIP rates to facilitate
negotiations with state (possibly pursue risk adjusted rates) and improve financial
forecasting and budgeting
• Retain a claims auditing organization on a contingency fee basis to identify and
recover claims paid incorrectly
• Develop a data warehouse and acquire a decision support solution (including
provider profiling) to identify cost, utilization and quality drivers
2
POTENTIAL SAVINGS
Reduce administrative costs to 12 % of revenue $3,700,000

Pay Medicaid rates to Children’s Medical Center 1,500,000
Eliminate $3 PCP gatekeeping fee (establish incentive pool) 2,000,000
Recover claims paid incorrectly 500,000
Reduce CHIP payments to non-participating providers 500,000
TOTAL $8,200,000
3
Deliverable: Identify the total resources by source (i.e., Medicare, Medicaid,
taxes, other public and private sources) that are dedicated to low income care.
Table 1 identifies the resources, by source, that are dedicated to low-income care in
Dallas County. All data is from 2002, the most recent year for which complete data is
available. In 2002, more than $1.6 billion was expended for low-income health care in
Dallas County.
Medicaid/SCHIP
Medicaid accounted for the vast majority of available funding for low-income health care
in Dallas County at a little over $1.2 billion in 2002. Medicaid is a joint state and
federally funded program targeting low-income families, those receiving cash benefits
through other federal programs and low-income elderly and disabled individuals. In the
state of Texas in 2002, Medicaid benefits are available, depending upon eligibility
category and family composition, to individuals earning between 0% and 185% of the
federal poverty level (FPL). The $1.2 billion figure includes payments for services
received by individuals enrolled in Medicaid managed care plans and those enrolled in
fee-for-service Medicaid. It also includes direct payments to hospitals that serve a
disproportionate number of individuals who are either uninsured or covered by Medicaid,
through Texas’ Medicaid Disproportionate Share Hospital (DSH) program.
Approximately $220 million, about 18% of total Dallas Medicaid spending, of the $1.2
billion was spent for nursing home services.
State of Texas State Children’s Health Insurance Program (SCHIP) funds accounted for
about $55 million in fiscal year 2002. SCHIP is another joint state and federally funded
health insurance program. This program provides health insurance coverage for children
up to age 19 ineligible for Medicaid with family income below 200% FPL.
Substantial changes were made to Medicaid and SCHIP eligibility during the 2003
legislative session for the final FY2004-2005 biennium budget. HHSC and state officials
projected children’s Medicaid and SCHIP enrollments to be 577,981 less in FY2005 and
that total savings for the biennium budget at more than $1.6 billion.1 Based upon
spending and enrollment assumptions, it is projected that this will reduce spending for the
biennium by approximately $140 million and enrollments by approximately 50,000
members in Dallas County2. The cuts were driven primarily by reducing continuous
eligibility, establishing a 90-day waiting period, higher cost sharing requirements,
eliminating a number of optional medical services, and provider rate cuts.
Medicare
Medicare is not a means-tested program, and reliable data on Medicare spending on low-
income beneficiaries is not readily available. Therefore, this analysis includes only those
Medicare resources expended in Dallas County through the Medicare Disproportionate
Share Hospital (DSH) program, which funds hospitals that serve a large proportion of
Medicaid patients and low-income Medicare patients. Dallas County hospitals received
1
“Children’s Medicaid and SCHIP in Texas: Tracking the Impact of the Budget Cuts”. Kaiser
Commission. July, 2004.
2
Impact prorated from HHSC Reports
Health Management Associates Appendix I

Medicare Disproportionate Share (DSH) payments from the federal government in excess
of $34 million in fiscal year 2002.
Tax Support
The Dallas County Hospital District (Parkland Hospital and Health System) received
$311 million in tax support in 2002 for indigent health care. This is based on the current
rate of $0.254 per $100 of assessed value.
Other Public
The city of Dallas spent slightly more than $5 million on low-income health care
services. The majority of this spending came from the city’s general fund to finance
neighborhood clinics providing health screening and immunization services. The city also
received about $725,000 in grant funding from the Texas Department of Health (TDH)
for disease screening, immunization and lead abatement initiatives.
The Dallas County Health Department accounted for about $11.5 million of the total
resources dedicated to low-income health care in the county. The department expended
about $7.2 million of general fund dollars to health administration, public health and
disease prevention efforts and administered an additional $4.3 million in grant funding
for disease prevention, training and immunization efforts.
The Dallas County Hospital District received $3.4 million in 2002 from tobacco
settlement proceeds, pursuant to the settlement agreement dated July 18, 1998. Under the
agreement, "all hospital districts, other local political subdivisions owning and
maintaining public hospitals, and counties of the State of Texas responsible for providing
indigent care to the general public” are eligible to receive funds.
Parkland Foundation
The Parkland Foundation is a nonprofit corporation organized in Texas in 1985 to
support and benefit Parkland exclusively. The Foundation’s mission is to provide
resources and promote community involvement to embrace the mission and vision of
Parkland. Expenditures represented in the table are the support for low-income patients
channeled directly or through the Parkland Foundation to Parkland Health and Hospital
System in 2002.
2002 Expenditures for Low-Income Healthcare in Dallas County, By Source

2002
Dallas
2002 County
Program Expenditures Enrollment Source
Medicaid $1,202,119,500 190,000 HHSC
SCHIP $54,962,100 47,800 HHSC
Medicare DSH $34,454,800 NA Centers for Medicare and Medicaid Svcs.
Tax Support $310,763,000 NA 2002 Dallas County Budget
Other Public $20,153,800 NA
Tobacco Settlement $3,380,300 NA Texas Department of Health
Dallas City $5,241,800 NA 2002 Dallas City Budget
Dallas County Health Dept. $11,531,700 NA 2002 Dallas County Budget
Parkland Foundation $8,163,600 NA Parkland Foundation
Total $1,630,616,800 237,800

Deliverable: Identify the standard of indigence used by the Hospital District, what
standard is used by adjacent counties and what are the options that may or should
be considered as a reasonable standard for eligibility for indigent care.
Deliverable: Identify the surrounding counties’ standard of indigency for medical

services, the amount of healthcare funding set aside and dollars expended by
counties for low income citizens. This analysis should include the level and scope
of publicly and privately funded health care including non-facility based resources
available in the surrounding counties and their funding source.
STATE LAW REQUIREMENTS – INDIGENT HEALTH CARE
In Texas, indigent care is primarily provided by hospital districts, public hospitals and
county run programs operated under the umbrella of the County Indigent Health Care
Program (CIHCP). Counties that are not fully served by a public hospital or hospital
district are responsible for administering a CIHCP for indigent residents of all or any
portion of the county not served by a public hospital or hospital district. With the recently
created hospital district in Travis County, almost all urban counties currently operate
hospital districts. Most public hospitals are located in hospital districts and, therefore, fall
under the hospital district guidelines. The following table provides a summary of the
indigent care delivery mechanism in Texas counties:
Indigent Care Delivery Mechanism Number of Counties

County Run Programs (CIHCP) 142
Hospital Districts 120
Public Hospitals 25
State Law Standards of Indigence – County Indigent Health Care Programs
State law establishes minimum requirements for counties in establishing eligibility and
service standards for indigent care. The eligibility standard for indigence includes four
factors:
¾ Income level – as measured against the federal poverty level

¾ Asset/resource test – the level of resources owned, for example, the value of a car
¾ Household composition – whose income is counted toward the standard
¾ Residency – where a person must live to be eligible for services
These factors are detailed below (addition detail is contained in Attachment 2):
Income Requirements. State law eligibility standards for CIHCP classify income as
exempt or non-exempt for purposes of counting towards income eligibility limits.
Exempt income is not counted towards determining whether a person meets the standard.

Exempt income includes income such as child support up to a certain amount;
educational assistance such as Pell Grants; government programs such as SSI, TANF,
Food Stamps, and Foster Care; and cash contributions from exempt persons for common
household expenses such as rent or food. Examples of income that does count towards
eligibility limits includes military pay, pensions, disability insurance benefits, dividends
and royalties, interest, self-employment income minus business expenses, worker’s
compensation, unemployment compensation, and VA benefits.
The countable eligibility level for the CIHCP program is gross monthly income, minus
standard work related expense deductions from earned income. The minimum required
eligibility level for CIHCP programs is 21% of the Federal Poverty Level, but counties
may choose to use higher income limits up to 125% FPL and be eligible for State
matching funds (see below). However, most CIHCPs set their standard at the minimum –
21% FPL.
Asset/Resource Requirements. State law standards for CIHCP also apply an assets test,
comparing a person’s resources against a maximum amount for purposes of eligibility. A
CIHCP household is not eligible if the total countable household resources exceed $2,000
on or after the first application date. If the applicant or a relative living in the home is
aged or disabled, the household resources cannot exceed $3,000 on or after the first
application date. As with income, certain resources are considered exempt for purposes
of the eligibility standard, including 401K, burial plot, homestead, life insurance,
personal possessions, vested retirement accounts, and vehicles with a fair market value of
less than or equal to $4,650. Non-exempt resources include IRAs; insurance or lawsuit
settlements; liquid resources such as cash or a checking or savings account; and the fair
market value of vehicles in excess of $4,650.
Household Composition Requirements. State laws for CIHCP eligibility also consider
household composition in apply income eligibility standards. CIHCP household
composition consists of those persons living together who are legally responsible for each
other, such as parents and minor children and spouses. Medicaid recipients are
disqualified household members and not considered in determining household income.
Residency Requirements. Under the CIHCP, state law requires that applicants must live
in the Texas County in which they apply. There are no durational requirements for
residency and intent is a major factor in determining residency. People who have access
to services from other counties are not considered residents, for example minor students
supported by their parents, inmates or residents of a state school, and persons living in
areas served by a public hospital or hospital district.
Required Services – County Indigent Health Care Programs
State law requires CIHCP counties to provide basic health care services, including
primary and preventive services such as immunizations, inpatient and outpatient hospital
services, physician services, prescription drugs, skilled nursing facility care, rural health
care clinic services, family planning, and lab and x-ray. Texas Health and Safety Code
Section 61.028 (See Attachment 1 for a complete listing).

The Health and Safety Code also provides state matching funds for certain optional
services provided by CIHCP counties, including emergency services, ambulatory surgical
center services, diabetic supplies, durable medical equipment, home and community
health care services, counseling, dental care, vision care, FQHC services, and services by
certain health care practitioners such as certified nurse midwives and physician assistants.
Texas Health and Safety Code Section 61.0285 (See Attachment 1 for a complete listing)
Other Requirements – County Indigent Health Care Programs
Matching Funds. A CIHCP county may qualify for state assistance funds if they expend
8% of their General Revenue Tax Levy (GRTL) on TDH-established basic services or
TDH-approved optional services for qualified individuals. Eligible CIHCP counties
receive a 90/10 match for services above the 8% GRTL. TDH administers this state
assistance fund.
Enforcement. Texas Department of Health (TDH) has no enforcement authority but does
handle eligibility dispute request resolutions between providers and counties, public
hospitals, and hospital districts. Program administration is solely the responsibility of the
county government, hospital district, or public hospital.
Payment Standards for Services. State law also establishes standards related to how
counties pay providers for services. The TDH-established payment standards for CIHCP
services are based on the Medicaid rates and are updated periodically. Counties are not
legally liable for more than the TDH-established payment standards. At the beginning of
each calendar year counties must choose to pay for inpatient hospital services by either
the Medicaid inpatient percentage rate or the Medicaid DRG (Diagnostic Related Group)
prospective payment amount. A county using DRGs for inpatient hospital payment must
pay the DRG amount regardless of the amount billed. However, a county may negotiate a
contract with a provider to pay an amount below the established payment standard.
Limitation of County Liability. In addition to income eligibility limits, state law also
imposes a cap on a county’s responsibility for health care. The maximum county liability
for each state fiscal year for health care services provided by all assistance providers,
including hospital and a skilled nursing facility, to each eligible county resident is:
1. $30,000; or
2. The payment of 30 days of hospitalization and/or treatment in a skilled nursing
facility, or $30,000, whichever occurs first.
Payor of Last Resort. CIHCP counties are the payor of last resort, but they can pay for
services at state hospitals or clinics. Counties may also rely on other health care sources
that might reduce costs, including the Texas Department of Human Services, Texas
Rehabilitation Commission, Texas Department of Health, Social Security Administration,
Veteran's Administration, or Attorney General's Office (Victims of Violent Crimes).
State Law Standards of Indigence – Hospital Districts

In Texas, hospital districts in major urban areas are established under Article IX, Section
4 of the Texas Constitution and Chapter 281 of the Texas Health and Safety Code. They
are political subdivisions of the State of Texas, created to provide medical and hospital
care to the needy and indigent county residents. As hospital districts under state law, they
qualify as governmental entities.
As taxing entities, hospital districts can only be created pursuant to an election by the
county residents. The election sets the authority of the entity to collect taxes and
establishes a maximum tax rate. Under the law, hospital districts are payors in the sense
that they collect taxes and pay for services. Hospital districts have the authority and the
option to operate hospital systems or to contract for hospital and other medical services,
and have the authority to create affiliated entities such as managed care organizations.
That is, a hospital district’s delivery system is not mandated by state law.
Hospital Districts cannot establish income, household composition, and resource

eligibility standards that are more restrictive than the legal minimum standards for
CIHCP counties, and they must “endeavor to provide” the basic services that CIHCP
counties must provide. Texas Health and Safety Code Sections 61.055(a), 61.006(b),
61.052.
Most hospital districts significantly exceed the minimum income requirement specified in
State law, setting their standard at 100% of the FPL or above.
State Law Requirements Related to Residency. The Texas Health and Safety Code
includes requirements for residency for purposes of eligibility for services from a hospital
district. These provisions include:
• “a person is presumed to be a resident of the governmental entity in which the

person's home or fixed place of habitation to which the person intends to return after a
temporary absence is located.” Texas Health & Safety Code § 61.003(a)
• “If a person does not have a residence, the person is a resident of the governmental
entity or hospital district in which the person intends to reside.” Texas Health &
Safety Code § 61.003(b)
• “The burden of proving intent to reside is on the person requesting assistance.” Texas
Health & Safety Code § 61.003(e)
• “A person is not considered a resident of a hospital district if the person attempted to

establish residence solely to obtain health care assistance.” Texas Health & Safety
Code § 61.003(d)
STANDARD OF INDIGENCE – DALLAS COUNTY HOSPITAL DISTRICT
Eligibility Requirements, Parkland Health and Hospital System
Parkland cites Chapter 281 of the Texas Health and Safety Code as establishing primary
responsibility with the Hospital District for providing medical care to the indigent
citizens of Dallas County, Texas. Parkland also cites the provision which authorizes the

hospital district to apply eligibility criteria to applicants and their legally responsible
relatives to determine whether an applicant is required to pay for part of the care
provided. See Texas Health ad Safety Code Section 281.071(a).
Parkland Health and Hospital System, the Dallas County Hospital District, considers five
elements when determining eligibility for the Parkland HealthPlus program – residency,
existence of 3rd party coverage, identification, household composition, and income:
Residency. Applicant must have an established residence in Dallas County at time of

treatment. Residents of the City of Dallas where the city limits have crossed into Collin
or Denton counties are excluded. Applicants who come to Dallas County for the sole
purpose of obtaining medical care are also excluded, a requirement reflected in state law.
The Texas Health and Safety Code also recognizes that residency can be established
based on the intent of the person, though the burden of proving intent falls on that person.
Parkland’s requirements do not address “intent” to reside in the county.
Third Party Coverage. Applicants who have access to health insurance are not eligible
for PHP even when they may not be covered. Applicants who are not able to access
employer provided health insurance due to a preexisting condition or a probationary
period are not eligible for PHP. Further, applicants who have missed the enrollment
period or who have elected not to participate in employer provided health insurance are
also not eligible.
Identification. Parkland requires proof of an applicant’s identification, such as a passport

or a driver’s license. A picture identification is not required, however, and wage stubs,
voter registration cards, and church referral letters for example are acceptable forms of
identification.
Household Identification. Parkland considers a household to be a person living alone or

persons living together where one or more individuals have a legal responsibility for the
support of the others. Individuals receiving TANF or SSI are excluded.
Income. Parkland HealthPlus enrollees must have income below 200% of the federal
poverty level (FPL). Prior to April 1, 2004, PHP covered individuals up to 250% FPL,
but new enrollment for the 200-250% FPL group has since been eliminated (coverage
continues for those already enrolled in the plan).
Parkland considers income as any type of payment or recurring benefits received that is
of gain to a household, including earned and unearned income. Monthly household
income is verified and compared to the “Qualified Income Levels Chart” included in the
Appendices of the Parkland HealthPlus Eligibility Manual.
Comparison with Selected Texas Hospital Districts
JPS Health Network, the Tarrant County Hospital District, considers similar elements
when determining eligibility for its indigent care program, JPS Connection. Eligibility is
based on household size and gross monthly income according the current federal poverty
level and proof of current residence in Tarrant County. The program is available for

persons who do not have Medicaid, Medicare with prescription benefits or any medical
coverage that covers all or part of medical services or pharmaceutical costs.
JPS Connection covers individuals with income up to 200% of the federal poverty level,
with graduated co-pay requirements at two levels (0 to 133% FPL; 134% to 200% FPL).
The hospital district also provides a program for the Medically Indigent, which offers
some coverage for patients who are uninsured or underinsured with high medical bills.
The Harris County Hospital District. considers residency, third party coverage,
identification, household composition, and income levels to determine eligibility for
coverage. Citizenship is not required to qualify for financial assistance, though
documentation from INS is required to determine eligibility for assistance (i.e., to
determine legal status). Harris County covers individuals up to 250% FPL. Individuals
below 100% FPL have no co-pay. Individuals between 100 and 200% FPL pay graduated
co-pays. Individuals above 200% FPL must pay half of total charges.
University Health Systems, the Bexar County Hospital District considers residency, and
income levels as criteria for participation in the CareLink program, which is a managed
care program for eligible patients. The Hospital District also provides financial
assistance for patients who do not fit the participation requirements for the CareLink
program. A person is considered a resident if the person’s home or fixed place of
habitation to which the person intends to return after a temporary absence is located in
Bexar County. A person’s citizenship status is not considered in determining residency.
Residents are consider indigent and eligible for assistance if they fall at or below 75% of
FPL based on gross family income and family size. Residents are considered needy and
eligible for assistance if they fall between 76% and 185% of FPL based on gross family
income and family size.
STANDARD OF INDIGENCE – ADJACENT COUNTIES
Eligibility Requirements for all Counties Adjacent to Dallas County
With the exception of Tarrant County, the counties adjacent to Dallas County (Collin,
Ellis, Denton, Kaufman, Johnson, Rockwall and Tarrant) are covered by the County
Indigent Health Care Act. Denton and Johnson counties, though adjacent to Dallas
County, are also adjacent to another large urban center with a hospital district – Tarrant
County.
As with most of the CIHCP counties in Texas, none of the counties adjacent to Dallas
County established income eligibility standards higher than the minimum, 25% of FPL,
nor do any of the counties identified by Parkland as major “feeder” counties for indigent
patients (Grayson, Navarro, Lamar).
With the exception of Collin County, all of the counties contiguous to Dallas County
requested funding for optional services in 2003. However, Johnson County was the
adjacent county that spent sufficient funds to qualify for state matching assistance. All
other adjacent counties provided less than 8% of their General Tax Levy towards health
care services under their CIHCP programs.

Comparison with Adjacent Counties and Other Selected CIHCP Counties (2003)
County Program Type % FPL % of County State Optional Services
General Tax Matching Provided**
Levy* Funds
Counties Adjacent to Dallas County
Collin CIHCP 25% 2.6% None
Denton CIHCP 21% 3.94% Diabetic Supplies
Ellis CIHCP 21% 4.19% Diabetic Supplies
Johnson CIHCP 21% 12.70% $588,868 Ambulatory Surgical Center,
FQHC
Kaufman CIHCP 21% 0.46% Diabetic Supplies
Rockwall CIHCP 21% 1.06% Certified Registered
Nurse Anesthetist
Diabetic Supplies (Syringes,
lancets, and test strips only)
Tarrant Hospital District 200%*** NA NA NA
Other Selected Counties
Bexar Hospital District 185% NA NA NA
Grayson CIHCP 21% 9.57% $226,673 Advance Practice Nurse
Ambulatory Surgical Center
Cert. Reg. Nurse Anesthetist
Colostomy Medical
Supplies
Dental Care
Diabetic Supplies
FQHC
Physician Assistant
Harris Hospital District 250%**** NA NA NA
Lamar CIHCP 21% 9.49% $107,929 Ambulatory Surgical Center
Cert. Reg. Nurse Anesthetist
Diabetic Supplies
Navarro CIHCP 21% 4.33%
Potter Hospital District 150% NA NA NA
Randle CIHCP 21% 4.08%
Source: County Indigent Heatlhcare Spending for FY 2003, County Spending Compared
to GRTL.
*Note: Only twenty counties received state matching funds for FY 2003. Those counties are: Aransas,
Atascosa, Callahan, Cameron, Coryell, Dewitt, Eastland, Fannin, Grayson, Guadalupe, Hidalgo, Johnson,
Kinney, Kleberg, Lamar, Medina, Montague, Morris, San Patricio, and Somervell
**Note that 65 counties requested funding for optional services. Those are: Aransas, Archer, Atascosa,
Austin, Bandera, Bastrop, Bell, Brown, Burnet, Callahan, Cass, Chambers, Cherokee, Colorado, Comal,
Coryell, Crosby, Delta, Denton, DeWitt, Duval, Eastland, Ellis, Erath, Fannin, Fayette, Galveston,
Grayson, Hale, Hamilton, Hardin, Harrison, Hays, Hidalgo, Hill, Howard, Irion, Jasper, Jim Hogg, Jim
Wells, Johnson, Kaufman, Kerr, Kleberg, Lamar, La Salle, Lee, Liberty, McLennan, Medina, Milam, Mills,
Newton, Orange, Polk, Rockwall, San Patricio, Smith, Somervell, Taylor, Tom Green, Uvalde, Waller,
Webb, Wise.
*** Tarrant requires graduated co-pays, in two levels (0 to 133% FPL and 134% to 200% FPL).
**** Harris County’s Gold Card program has no co-pays up to 100% FPL and graduated co-payments up
to 200% FPL. Patients between 200 and 250% FPL are asked to pay half of charges (source: Morningside
Research, “Comparison of Texas Hospital District Costs” August 29, 2002.)

ADDITIONAL INDIGENT CARE RESOURCES IN SURROUNDING COUNTIES
In addition to care financed through the County Indigent Care Programs, some private
foundations offer grant programs that direct resources toward low-income care. Examples
include the Harris Methodist Health Foundation and the Collin County Health Care
Foundation. Hospitals located in the surrounding counties also provide some level of
uncompensated care. The following table provides an estimate of the uncompensated care
provided:
2002 Uncompensated Care Provided by Hospitals in Surrounding Counties (000s)

Bad Debt Charity Total Total Uncompensated
Charges Care Uncompensated Uncompensated Care as Percent
Charges Care Charges Care Cost* of Total Charges
Collin $38.2 $10.4 $48.6 $19.5 4%
Denton $47.3 $4.0 $51.3 $20.5 4%
Ellis $6.2 $4.6 $10.8 $4.3 10%
Henderson $18.6 $13.8 $32.4 $12.9 23%
Kaufman $10.0 $2.9 $12.9 $5.2 11%
Rockwall $6.6 $0.7 $7.3 $2.9 6%
TOTAL $127.0 $36.4 $163.4 $65.3 5%
Source: 2002 TDH/AHA/THA Annual Survey.
*Cost information was not available; HMA estimated costs off of the charges provided in the report (cost-
to-charge ratio = 0.40)
OPTIONS FOR REASONABLE DALLAS COUNTY HOSPITAL DISTRICT

INDIGENCE STANDARD
An analysis of 2003 data on utilization by Parkland Health Plus patients reveals that the
vast majority of utilization is by PHP enrollees in the lowest income group (0% to 133%
FPL). Therefore, even a large change in the income standard in Dallas County would
appear to have little impact. Data on PHP utilization also show that a sizable portion of
PHP inpatients (62%) are admitted through the emergency department, indicating a
serious medical condition and likely care that Parkland would provide regardless of PHP
eligibility. Less than 5% of PHP outpatient utilization comes through the emergency
department, which is an indicator that PHP coverage may effectively divert individuals
from using the emergency room as a source of primary care. PHP’s apparent
effectiveness in diverting primary care from the emergency room may warrant further
analysis of the current PHP policy that denies eligibility to individuals who are offered
employer-sponsored insurance, regardless of its affordability. Parkland may want to
consider a less restrictive policy that imposes an affordability test before denying PHP
eligibility on this basis.
2003 Parkland Health Plus Utilization

Inpatient Inpatient Outpatient Outpatient
Though ED Other Through Other
ED

PHP Level 2 0% to 133% 2,089 1,241 15,749 284,846
FPL
PHP Level 3 133% to 200% 371 253 2,534 63,743
FPL
PHP Level 4 200% to 250% 21 34 192 5,735
FPL
Total 2,481 1,528 18,475 354,324
Efforts should be focused instead on means for stabilizing the existing safety net in
Dallas County by accessing appropriate levels of Federal matching funds, and evaluating
more equitable methods for financing care provided to non Dallas residents, particularly
for trauma services. These issues are discussed in detail in Chapter 2 of this report.
*Sources: County Indigent Health Care Program Provider Manual and Indigent Health Care Program
Handbook Revision 04-03

Deliverable: Identify the policy the Hospital District uses for providing care to
undocumented immigrants, what is the legally required care that must be provided and
what options may or should be considered for providing care to undocumented
immigrants and international visitors and the estimated cost of such care
BACKGROUND STATISTICS
As of 2000, Dallas County had approximately 2.2 million residents. The U.S. Census
Bureau estimates about 21 percent of Dallas County’s residents were foreign born. Of
these foreign born residents over 75 percent of them, or over 360,000, were not U.S.
citizens.3 Non-citizens are more likely to live in poverty and less likely to have health
insurance than Dallas County residents who are U.S. citizens.
Counties contiguous to Dallas County include Kaufman and Rockwall counties to the
east, Tarrant County to the west, Denton and Collin counties to the north, and Ellis
County to the south.4 The surrounding counties have much smaller populations of non-
citizen, foreign born than Dallas County. For instance, in Tarrant County, the county with
the next highest percentage of non-citizens, less than 9 percent of the county’s residents
fall in this category while more than 16 percent of Dallas County’s foreign born residents
are non-citizens.
Foreign Born by Selected Texas Counties (2000)

Dallas Tarrant Collin Denton Ellis Kaufman Rockwall
County, County, County, County, County, County, County,
Texas Texas Texas Texas Texas Texas Texas
Total Population 2,218,899 1,446,219 491,675 432,976 111,360 71,313 43,080
Foreign born: 463,574 183,223 65,279 40,591 7,907 4,039 3,364
Naturalized citizen 102,201 56,074 22,237 14,061 2,031 1,303 1,312
Not a citizen 361,373 127,149 43,042 26,530 5,876 2,736 2,052
U.S. Census Bureau, Census 2000
LAWS AND REGULATIONS AFFECTING UNDOCUMENTED IMMIGRANTS
There are numerous federal and state laws, regulations and policies that impact
undocumented immigrants’ access to healthcare and a provider’s ability to offer
treatment. The provisions detailed in this document vary. EMTALA is a federal
provision that requires hospitals to provide care. Other provisions provide funding for
hospitals to seek reimbursement.
Federal Laws That Affect Undocumented Immigrants
EMTALA. In 1986, Congress passed the Emergency Medical Treatment and Active
Labor Act (EMTALA), which requires hospitals and emergency personnel to screen, treat
3
U.S. Census Bureau, Census 2000
4
The Handbook of Texas Online http://www.tsha.utexas.edu/handbook/online/articles/view/DD/hcd2.html

and stabilize anyone who seeks emergency medical care regardless of income or
immigration status. This federal statute imposes an obligation on any facility providing
emergency medical services.
EMTALA defines an emergency as a condition manifesting itself by acute symptoms of

sufficient severity such that the absence of immediate medical attention could reasonably
be expected to result in placing the individual’s health in serious jeopardy.
Penalties related to a failure to comply with EMTALA include:

¾ A civil penalty of $50,000 per violation for a hospital with more than 100 beds.
¾ A maximum civil penalty of $25,000 per violation for facility with less than 100 beds.
¾ A maximum civil penalty of $50,000 per violation for physicians.
However, if a violation is found to be gross, flagrant, or repeated, physicians and hospitals may
be excluded from participating in Medicare, Medicaid or state health programs. Further,
individuals harmed by an EMTALA violation may file civil suits against both physicians and the
emergency facility.
Emergency Medicaid. As discussed above, EMTALA creates an obligation to treat
patients who present with an emergent condition. “Emergency Medicaid” reimburses
providers for emergency medical services and childbirth related care rendered to
undocumented immigrants who, except for their immigration status, would otherwise
qualify for the Medicaid program.
In fiscal 2003, Dallas County served approximately 17,000 unique individuals under
Emergency Medicaid for a cost of $99.5 million5 While Emergency Medicaid has
provided reimbursement for some emergency services delivered to the undocumented
immigrant population, many patients do not qualify for coverage because they do not
meet state Medicaid eligibility criteria (for example low-income adults without children).
In addition, certain medical expenditures that occur after a patient has been stabilized and
an emergency no longer exists do not typically qualify for reimbursement from the
federal government.
PRWORA. While the federal government authorized Medicaid reimbursement for

emergency services for undocumented immigrants that would have qualified for a
Medicaid program had they been US citizens, Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (PRWORA) limited immigrants access to
Medicaid benefits. PWORA allows access only to emergency health services and non-
Medicaid funded public health assistance (e.g., immunizations, communicable disease
treatment) and delays eligibility for non-emergency benefits for legal immigrants until
five years after citizenship is granted.6 In addition, PRWORA requires states that want to
provide non-emergency medical assistance to "non-qualified" immigrants to pass
affirmative legislation before providing such services, even if the state already had such a
law in place prior to the federal Act’s passage.7
5
Texas Health and Human Services Commission --- 9/3/04 e.mail correspondence.
6
Eldridge, Jennifer, Health Care Access for Immigrants in Texas, Working Paper from the Policy Research
Project on Expanding Health Care Coverage for the Uninsured , The Lyndon B. Johnson School of Public
Affairs, The University of Texas at Austin, May 2002.
7
U.S. Public Law 104-193, Sec. 431, 104th Cong., 2d Sess. Personal Responsibility and Work Opportunity
Reconciliation Act of 1996. August 22, 1996

In 2003 Texas passed legislation affirmatively authorizing the provision of non-
emergency services to undocumented.
Medicaid and SCHIP Exclusion. Federal law further impacts funding for services to
undocumented immigrants by excluding undocumented children from Medicaid and
State-Children’s Health Insurance Program (SCHIP) enrollments. There are minor
provisions in SCHIP that allow for some funding to effectively be permitted for
undocumented immigrants.
USCIS Statutes and Policies. Although less visible than the federal statutes already
noted, a number of provisions within the US Citizenship and Immigration Services
(USCIS) Bureau (formerly Immigration and Naturalization Service (INS)) directly affect
the level of uncompensated care experienced by hospitals and emergency medical
services (EMS) providers in border states. Prosecutorial discretion and Parole Authority
are key policies that often dictate how immigration issues are handled. Unfortunately
while they permit authorized status in the U.S., no funding has been appropriated to
support these admissions for health care services.
State Laws That Affect Medical Care for Undocumented Immigrants
Indigent Health Care and Treatment Act. Chapter 61 of the Texas Health and Safety
Code, “Texas’ Indigent Health Care and Treatment Act”, gives Texas hospital districts
discretion to set eligibility standards for health services with the provision that the
district does not set income eligibility below 21 percent of the federal poverty level
(FPL).8 The act specifically provides that a hospital district shall provide health care
assistance to each eligible resident in its service area who meets the basic income and
resources requirements established by the state and the district. Chapter 281 of the Texas
Health and Safety Code requires hospital districts to provide “medical aid and hospital
care to indigent and needy persons residing in the district” The district may define
“resident.” The Health and Safety contains no provisions or exclusions related to
citizenship and eligibility for hospital district provided services.
Interpretation of PRWORA. In July 2001, Texas Attorney General John Cornyn issued
a written opinion in response to an inquiry from the Harris County Hospital District
maintaining federal law prohibited county hospitals from using public money to provide
non-emergency services to undocumented immigrants. The Attorney General’s opinion
stated that the federal Personal Responsibility and Work Opportunity Reconciliation Act
(PRWORA) of 1996 prohibits the use of public funds to provide non-emergency services
to undocumented residents unless a state law passed after PRWORA’s passage
affirmatively grants authority to do so. The opinion further stated that recent Texas laws
were not sufficiently explicit in reauthorizing such spending and that provision of this
care was illegal. The opinion is nonbinding, and does not carry the weight of law, but it
opened public hospitals to legal challenges.
8Texas Health & Safety Code, Subtitle C. Indigent Health Care Chapter 61. Indigent Health Care And Treatment Act

Act Clarified. This opinion generated legislation to correct this oversight. In the 2003
Legislative Session language was incorporated into HB2292, 78th Regular Session.
Section 285.201”Provision of Medical and Hospital Care”:
“As authorized by 8 U.S.C. Section 1621(d), this chapter affirmatively

establishes eligibility for a person who would otherwise be ineligible
under 8 U.S.C. Section 1621(a), provided that only local funds are utilized
for the provision of non-emergency public health benefits. A person is not
considered a resident of a governmental entity or hospital district if the
person attempted to establish residence solely to obtain health care
assistance.”
This provision clarifies that public entities, including hospital districts, may provide non-
emergency services to undocumented or non-citizen immigrants as long as they did not
enter the U.S. solely for the purpose of obtaining health care.
New Funding for Emergency Treatment of Undocumented
MMA. Although much federal legislation has limited federal reimbursement for medical
services provided to undocumented immigrants, recent passage of the Medicare
Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 offers some
financial relief. Section 1011 of this Act appropriates $250 million per year nationwide.9
Allocations to states will be based on the number of US Citizenship and Immigration
Services Bureau apprehensions in each state. Reimbursement for emergency medical
treatment provided to undocumented immigrants will be made directly to eligible
providers which include hospitals, physicians, and ambulance service providers.
This section of law takes affect October 1, 2004. CMS published initial guidance on
implementation of Section 1011 in August 2004. The initial guidance indicated that
hospitals would need to do the following in order to qualify for funds under Section
1011:
1. Determine the person does not have and does not qualify for another payment
source.
2. Determine the patient is undocumented or a “non-qualified” alien
3. Collect personal information of the patient including name, address and date of
birth.
4. Maintain documentation on the services provided and cost of the emergency
services provided for audit purposes.
A number of providers and advocacy organizations expressed concerns about CMS’

requirement that patient names and other identifying information be collected because
they fear it may discourage undocumented immigrants from getting needed care.
However, information regarding citizenship status is necessary to make an accurate
determination regarding eligibility for Medicaid and SCHIP. Most health facilities
9
U.S. H.R. 1. Medicare Prescription Drug, Improvement, and Modernization Act of 2003, January 7, 2003.

routinely conduct some medical assistance program eligibility screening. Many hospitals
are using software to screen for Section 1011 eligibility.
Table 1 shows CMS’ preliminary funding estimates per state under Section 1011 based
on 2000 apprehension data. Final allocations will be based on 2003 alien apprehension
data. Texas will receive about $48 million per year over the next four years.

Table 1: Section 1011 Preliminary State Allocations
Estimated Preliminary
Number of
Unauthorized State Allocations Projected State
Apprehensions
State Resident Based on % of Allocation
by State in FY
Population Undocumented (Total)
2003
(1/2000) in 000s Aliens
Alabama 24 $572.326 757 $572.326
Alaska 5 $119,236 278 $119,236
Arizona 283 $6,748,679 410,105 $41,579,731
Arkansas 27 $643,867 1,288 $643,867
California 2209 $52,677,852 231,523 $72,341,572
Colorado 144 $3,433,957 7,207 $3,433,957
Connecticut 39 $930,030 460 $930,030
Delaware 10 $238,469 0 $238,469
District of 7 $166,928 1,139 $166,928
Columbia
Florida 337 $8,036,413 9,510 $8,036,413
Georgia 228 $5,437,098 1,788 $5,437,098
Hawaii 2 $47,694 508 $47,694
Idaho 19 $453,092 1.131 $453,092
Illinois 432 $10,301,871 2,721 $10,301,871
Indiana 45 $1,073,112 605 $1,073,112
Iowa 24 $572,326 486 $572,326
Kansas 47 $1,120,805 0 $1,120,805
Kentucky 15 $357,704 656 $357,704
Louisiana 5 $119,235 4,110 $119,235
Maine 5 $11,923 380 $11,923
Maryland 56 $1,335,428 1,135 $1,335,428
Massachusetts 87 $2,074,682 1,532 $2,074,682
Michigan 70 $1,669,285 3,577 $1,669,285
Minnesota 60 $1,430,815 2,138 $1,430,815
Mississippi 8 $190,775 861 $190,775
Missouri 22 $524,632 4,099 $524,632
Montana .5 $11,923 1,063 $11,923
Nebraska 24 $572,326 2,683 $572,326
Nevada 101 $2,408,539 1,213 $2,408,539
New Hampshire 2 $47,694 470 $47,694
New Jersey 221 $5,270,170 1,963 $5,270,170
New Mexico 39 $930,030 49,421 $6,127,458
New York 489 $11,661,145 9,612 $12,477,512
North Carolina 206 $4,912,466 1,398 $4,912,466
North Dakota .5 $11,923 663 $11,923
Ohio 40 $953,877 1,320 $953,877
Oklahoma 46 $1,096,958 681 $1,096,958
Oregon 90 $2,146,223 2,306 $2,146,223
Pennsylvania 49 $1,168,499 3,374 $1,168,499
Rhode Island 16 $381,551 736 $381,551
South Carolina 36 $858,489 342 $858,489
South Dakota 2 $47,694 395 $47,694
Tennessee 46 $1,096,958 1,415 $1,096,958
Texas 1041 $24,824,647 267,081 $47,508,379
Utah 65 $1,550,050 2,503 $1,550,050
Vermont .5 $11,923 1,158 $11,923
Virginia 103 $2,456,233 408 $2,456,233
Washington 136 $3,243,181 4,564 $3,243,181
West Virginia 1 $23,847 169 $23,847
Wisconsin 41 $977,724 491 $977,724
Wyoming 2 $47,694 0 $47,694
7,003 $167,000,000 1,043,421 $250,000,000
Total
Source: Department of Homeland Security, Office of Immigration Statistics

Dallas County Hospital District Policy on Serving Undocumented Immigrants
Public hospitals typically have written policies governing who qualifies for their indigent
health care programs. Public hospitals and clinics throughout Texas have traditionally
provided care to undocumented immigrants on the same basis as other uninsured
residents. Generally, public hospitals and clinics do not require that patients be U.S.
citizens to receive non-emergency services, however, hospitals may inquire about INS
documentation to determine charity program eligibility.
Parkland HEALTHplus (PHP) is the program through which the Dallas County
Hospital District provides medical services to indigent residents of Dallas County. This
plan operates under the provisions of Chapter 61 of the Health and Safety Code of the
State of Texas. In 2004, this program has about 82,000 enrollees.
Eligibility for participation in PHP is dependent upon residency, income, household

composition and insured status requirements. Adherence to these requirements
must be documented to a representative of PHP prior to receiving services. There is
no specific provision in the PHP Eligibility Manual that states a person must be a
citizen to qualify for benefits. Parkland employees are required to ask applicants
for a Social Security number. It is not clear in written policy whether the lack of a
Social Security number is used to deny benefits to otherwise qualified individuals.
On a practical level, if a patient (emergency or non-emergency) does not share a
Social Security, this does not preclude the patient from eligibility in PHP. Once a
person has been found eligible to participate in PHP, this designation can remain in
effect for up to 12 months and can be retroactively applied for 12 months.
Eligibility for PHP coverage is calculated using a sliding scale based upon family size
and income. Patients who have a monthly gross income equivalent to 100% of FPL or
below are not required to participate in cost sharing, but PHP members with monthly
gross income between 133% and 200% of FPL are required to provide co-pays for health
services they receive. PHP coverage can also be used to supplement health benefits
offered through other government health programs like Medicare, Medicaid, Title V, VA
Health coverage and the Ryan White program.
The table below compares PHP’s indigent health care program eligibility criteria to the
policies of five hospital districts in Texas’ most populous counties. With the exception of
counties contiguous to the Texas/Mexico border these large, urban counties are likely to
have the largest indigent and immigrant populations.

Eligibility Criteria for Indigent Health Care Programs for Selected Texas Counties
Eligibility Criteria
Proof
Program of Verification Household Citizenship Asset
County Name Identity Residency Income of Income Composition Considered Limits Other
100% -
200%
FPL.
133-
200%
Parkland Resident FPL with
Dallas HealthPlus Yes of County co-pay Yes Yes No Yes
75 %
to 185
Resident % with Annual
Bexar Carelink Yes of County co-pay Yes Yes No recertification
Thomason Resident 50 % Yes
El Paso Cares Yes of County FPIG Yes No No None
INS
Resident documentation
Harris Gold Card Yes of County Yes Yes Yes Yes required
Up to
200 %
FPIG SSN for all
JPS Resident with Last 4 pay members of
Tarrant Connection Yes of County co-pay stubs Yes No Yes household
Medical Income for $5,000
Assistance Resident 100 % the past 30 - Over 67 up to
Travis* Program Yes of County FPIG days Yes No $10,000 200 % FPIG
Note: Travis County has only recently formed a Hospital District. Prior to that the City of Austin funded and
operated the Public Hospital.
RH2 Consulting, June 2004
Cost of Serving Undocumented Immigrants
The cost of serving undocumented immigrants who create uncompensated care has not
been definitely measured. Model based estimates are available for counties bordering
Mexico and some communities are beginning put methods in place to track actual levels
of uncompensated care attributable to undocumented immigrants. The economic analysis
prepared by Texas Perspectives Inc. for this report indicates that the 2004 cost for
uncompensated care at Parkland is approximately $260 million.
Approximately 360,000 non-citizens reside in Dallas County and another 208,000 reside
in the counties contiguous to Dallas County. Studies vary regarding the extent to which
uninsured affect health care premiums. A significant amount of published literature has
pointed out that bad debt and charity care typically between 16% - 30% to health care
premiums. Other works have pointed out that the cost-shifting is not significant since

because the majority of the uninsured receive care from safety net providers that do not
have a large enough base of private payers to support cost-shifting.10
OPTIONS FOR SERVING UNDOCUMENTED IMMIGRANTS AND COST OF

SUCH OPTIONS
As indicated previously, Parkland provides approximately $260 million in care for 2004
to undocumented immigrants. Given the federal EMTALA provision, the overwhelming
majority of this care must be provided as prescribed in federal law. The follow options
are important to consider as health care pressures continue for undocumented immigrants
in Dallas County:
• Primary Care Infrastructure Deflects More Costly Emergency Care.
EMTALA and other provisions essentially require that undocumented immigrants
are covered. Unfortunately, the federal provisions effectively funnel
undocumented immigrants into higher-cost settings, namely the emergency room.
The literature shows that using the emergency room for non-urgent care results in
charges that are two- to three times more than a visit to another setting.11 The
financial and clinical benefits of timely are especially well-documented for
pregnant women. Several studies show a positive relationship between
comprehensive prenatal care and reduction in low birth weight and infant
mortality. Inappropriate or no prenatal care can increase the risk of premature
delivery and/or low birth-weight infants. 12 The estimated average cost of
postnatal care for women without prenatal care was $3,930 compared to $1,589
for a woman who had prenatal care.13 Support for an undocumented immigrants
primary care infrastructure mitigates the high-cost loss in the emergency room.
• CMS Match. On November 11, 2002, CMS issued guidance to states to allow
states to use enhanced match SCHIP funds for unborn children and uninsured
low-income women. Labor and delivery costs are covered under Emergency
Medicaid but prenatal and potentially post-partum services could be covered
under this state plan amendment. This state plan amendment could impact health
status and positively affect revenues for Dallas County. The state has not filed a
state plan amendment to access federal funds. It is certainly worthy of
consideration to access matching funds for services that are currently being
provided and contribute towards cost-effective services (i.e. a healthy delivery).
Rhode Island, Illinois, Minnesota, Arkansas, Washington, Massachusetts, and
10
Holahan and Hadley, http://books.nap.edu/books/030908931X/html/55.html.
11
Baker LC and Baker LS, Excess Cost of Emergency Department Visits for Nonurgent Care, Health
Affairs; Winter 1994.
12
See for example, Howell EM, The Impact of the Medicaid expansions for pregnant women: a synthesis of
the evidence. Medical Care Research and Review. 2001 Mar; 58(1):3-30, and Lu MC, Lin YG, Prietto NM
and Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California:
A cost/benefit analysis. American Journal of Obstetrics and Gynecology. 2000 Jan; 181(1 part 1): 233-239.
13
Lu MC, Lin YG, Prietto NM and Garite TJ. Elimination of public funding of prenatal care for
undocumented immigrants in California: A cost/benefit analysis. American Journal of Obstetrics and
Gynecology. 2000 Jan; 181(1 part 1): 233-239.

Michigan already have approved state plan amendments. This care is currently
being provided by Parkland and other safety net hospitals and is paid for entirely
by local tax dollars. HMA estimates that this could yield additional revenue of
approximately $7 to $9 million.
• Develop 3 Share Option. Ineligible non-citizens have a positive impact on the
economy. Low-cost labor helps to fuel the economy nationally. Employers have
a great interest in this population. Exploring the opportunity of the 3 Share
Health Care Model that does not exclude ineligible non-citizens is a natural
staring point. A 3 Share Model that has funding support from the County (already
responsible for picking up the cost so this would not be additional money), an
employer (incentive to keep reliable employees), and the employee (several
potential incentives for employee participation if social is not required).
o The key design components for a 3 Share program are employer eligibility
criteria, employee eligibility criteria, dependent eligibility criteria, scope
of covered benefits and program administration. These programs have
typically been aimed at low-wage businesses that have been unable to
afford the cost of health insurance as an employee benefit. Despite this
commonality, the program elements vary greatly from community to
community, illustrating the range of options that are available.
o Each plan reflects a slightly different market approach, scope of services,
eligibility/membership options and participation requirements. An high-
acuity benefit package could be designed and or a primary care benefit
package. While programs have been designed with traditional workers in
mind, a model that does not include a social security number as a required
field for eligibility should be examined.
• MMA Funding. Monitor and access funding that has been made available
for the federal MMA impact as discussed previously.

Deliverable: Using a common, agreed to and articulated definition of costs, identify the
cost of charity, non-insured and non-compensated health care provided by the Dallas
County Hospital District to residents of Dallas County.
Deliverable: Using a common, agreed to and articulated definition of costs, identify the
costs of charity, non-insured and non-compensated health care provided by the Dallas
County Hospital District to non-residents of Dallas County.
The following table details the cost of unfunded (self-pay and charity care) care provided
by Parkland to Dallas County residents and non-residents in 2003.
Parkland Self-Pay and Charity Care at Cost (FY 2003) Before Tax and Tobacco
Allocations
Charges Direct Total Payment Allocat- Contr. Excess/

Cost Cost ions** Margin (Shortfall)
Dallas County $415.8 $132.4 $230.3 $9.4 $25.7 ($97.3) ($195.2)
Unfunded
Out-of-County $29.2 $8.3 $14.7 $1.1 $3.1 ($4.1) ($10.5)

Unfunded
Through ER $22.9 $6.1 $10.6 $0.6 $2.7 ($2.8) ($7.3)
Other $1.0 $0.3 $0.6 $0.0 $0.2 ($0.1) ($0.4)
Unavoidable*
Avoidable* $5.3 $1.9 $3.4 $0.5 $0.3 ($1.1) ($2.6)
All Unfunded $445.0 $140.8 $244.9 $10.5 $28.8 ($101.5) ($205.6)
Unfunded as % 37.1% 35.5% 35.2% 4.0% 24.4%

of Total
*As classified by Parkland; includes primarily transfer cases.
** Includes UPL, DSH, Other Patient revenue, and timing variances (to tie to G/L).
Deliverable: Using a common, agreed to and articulated definition of costs, identify

the cost of charity, non-insured and non-compensated healthcare provided in Dallas
County by other Dallas County Community Hospitals (both for-profit and non-
profit) to residents and non-residents of Dallas County.
The following table summarizes data provided to HMA by the members of the Dallas
Medical Resource (DMR) group, which includes some of the largest hospitals in Dallas
County. It is important to note that, due to data limitations, the table includes only
inpatient and emergency room activity, which constitute most, but not all of the unfunded
care provided by these hospitals. While Parkland is clearly the largest provider of

unfunded care in Dallas County, many of these hospitals also serve significant numbers
of the uninsured.
DMR Hospital Self-Pay and Charity Care (CY 2003) for Inpatient and Emergency
Department (000s)
Dallas Out-of-County Total Unfunded Unfunded

as % of
Total
Hospital Charges Cost Charges Cost Charges Cost Payment Charges
Childrens $6.7 $2.8 $2.6 $1.1 $9.3 $3.8 $0.6 1.5%
Presbyterian $30.0 $11.2 $9.4 $3.5 $39.4 $14.8 $1.5 5.0%
Methodist Char $17.4 $7.8 $2.8 $1.2 $20.1 49.0 $0.7 10.2%
Methodist Dal. $36.8 $17.6 $7.9 $3.8 $44.7 $21.4 $2.2 12.1%
BUMC $44.0 $16.1 $21.0 $7.7 $65.1 $23.7 $2.1 5.9%
Baylor Irving $15.0 $6.2 $2.0 $0.8 $17.0 $7.0 $0.5 7.4%
Baylor Gar. $13.3 $5.1 $2.0 $0.8 $15.3 $5.9 $0.4 8.6%
Medical City* $23.6 $5.9 47.8 $1.9 $31.4 $7.8 $1.6 NA
St. Paul $17.7 $7.5 $3.8 $1.6 $21.5 $9.1 $1.5 5.4%
Zale Lipshy** $2.9 $1.3 $1.0 5.1%
TOTAL $204.5 $80.2 $59.4 $22.5 $263.9 $102.7 $11.3 5.7%
Note that totals and percentages in this table vary from other presentations in this report. This table is
limited to Inpatient and ED data and, due to data limitations, does not include outpatient data.
*Medical City is excluded from totals due to insufficient information.
**Due to systems limitations, Zale Lipshy was unable to report data by County
Deliverable: Analyze the potential of creating an expanded hospital district which

includes surrounding counties whose citizens derive benefits from these services.
Introduction
The high percentage of uninsured persons in Dallas County has placed a significant
amount of pressure on the regional health care system. This factor coupled with the
changing composition of the population of counties contiguous to Dallas County and the
evolution of state and federal law in how indigent individuals are cared for have placed a
high financial burden upon Texas counties. This environment has made the concept of
expanding the Dallas County Hospital District to include surrounding counties worthy of
exploration.
HMA has examined current efforts aimed at regionalizing health services in Texas and
conducted interviews with political and administrative figures in surrounding counties to
determine the feasibility of expanding the hospital district beyond Dallas County.
Landscape
The Texas Senate Health and Human Services Commission is currently exploring the
concept of multi-county efforts to provide health services to the indigent. The
commission is studying ways to improve Texas’ county and local indigent health care

system. An element of this study is to examine “…whether the system should be
regionalized to reflect usage and gain efficiencies, so that one or more counties are not
paying for regional health care.”The report will be due in November 2004.
Contiguous Counties
Health Management Associates conducted a series of interviews with Judges,
Commissioners, and Administrators from counties contiguous to Dallas County. The
focus of the interviews was to understand contiguous counties indigency programs in
greater detail their views of Parkland Hospital. Several major themes became apparent
from discussions with representatives of these communities. These themes are discussed
below.
Counties More Open-Minded with Extra Funding - The idea of seeking additional or enhanced
federal funding garnered nearly universal support. Some individuals expressed frustration
with the role the state has played in not allowing federal funding to pass through to
counties. The view of many county representatives was that finding additional funding
sources for providing these services would reduce the tax burden upon county residents
used to fund indigent care.
Little Support for Raising Indigency Standard - The majority of counties bordering
Dallas County have set their standard for indigency at 21%, the minimum required by
state law. This level is far below the 200% set by Dallas County. Officials expressed
concern that raising the standard would provide an incentive for low-income individuals
to move to their county to take advantage of this service; that the state does not provide
financial support to make this change feasible; and that increasing this standard has
created financial difficulty in other counties.
Strong Criticism for the Out-of-County Billing Process and Press Coverage - County
officials expressed frustration that Parkland does a poor job screening patients and billing
for services rendered. One official reported that over a six-month period Parkland sent
hundreds of notifications to the county indigency office while only one resulted in a
person added to the county program. County officials felt that the media coverage of out-
of-county billings did not provide enough details to get accurate messages to readers.
Population Shifts Driving Change - Officials referred to population growth in their

counties and attributed it to flight from Dallas. Many expressed the belief that many of
their residents moved to their county to get away from the social and regulatory climate
of Dallas County.
Some Regional Activities Have Created Positive Past Experiences - Nearly all county
representatives referred to positive experiences working with other counties on regional
efforts. Many referred specifically to transportation and actions in response to the clean
air act as especially positive.
Regional Health Care Opportunities

One opportunity of regional health collaboration would be the creation of a Regional
Trauma Network. This network would allow Dallas and bordering counties to contribute

to a limited number of trauma facilities. This would allow the expertise in trauma care
gained by Parkland to be shared by bordering counties that often do not have the health
resources to effectively treat trauma cases. Depending upon how this would be structured
and worked out with Texas Medicaid, regional trauma an opportunity may be a platform
to draw down federal monies.
In discussions with county officials outside of Dallas, there was some interest in
exploring whether a trauma services could be shared across counties. These interviews
also revealed a generally positive history of inter-county efforts in this region.
Issues for Potential Development

• Regionalization of Trauma Network consideration
• Working with other counties to improve the billing process among counties
• Continue to explore opportunities for matching state and county services with federal
dollars

Parkland Health and Hospital System
ESI’s Assessment of the Revenue Cycle
October 2004
Objective
ESI’s objective was to evaluate the current state of the revenue cycle and determine if
additional opportunities existed to improve. Since Parkland has worked with a number of
consultants in the past few years in the revenue cycle area, our focus was to highlight
issues of substance that had not been exhausted. We did not see the largest gains coming
from highlighting the day to day detail challenges. Our focus took us outside of PFS in
some cases to highlight issues that we felt would drive more significant change over
time.We did spend some time validating the status of several current improvement
initiatives.
Scope
The scope of our engagement included Patient Financial Services (PFS), COPC, and the
outpatient clinics. PFS includes the emergency department. Primarily, this includes the
processes of registration, financial counseling, verification of benefits, billing,
collections, and certain other processes and areas that impact the revenue cycle such as
medical records or charge capture.
Approach
Our approach was to interview key stakeholders, observe processes, and analyze data to
support our findings and recommendations. We conducted more than 20 individual
interviews of people throughout the clinical, PFS, and administrative areas. This was
supplemented by many more in-depth conversations with key stakeholders in PFS.
The analysis of data was extensive in order to help drive where we looked for opportunity
and to substantiate those conclusions which were made.
Overall Observations
There are several issues that cannot be categorized as revenue cycle operational issues
but may have the most significant positive impact on Parkland’s ability to collect more
cash from operations.
• Parkland must embrace a single vision of how to deal with the financial obligation
of the patient. From interviews and observations, it is apparent that management
is not aligned in their message of how the financial mission of Parkland is to be
executed on a daily basis.
1
• Parkland should communicate the value of the services provided to each patient.
A statement of value that is relevant to the individual patient is more tangible to
that patient and may begin to change the behavioral expectation of the participant.
• Parkland has a number of initiatives in place and planned. Our process revealed a
need to become focused on a few initiatives and ensure success. Distraction was a
concept that was mentioned on more than one occasion. With a technology
implementation underway, Parkland must be focused in choosing efforts with
defined outcomes and allowing appropriate resources to attack the issues.
Consultants should be used when the scope is clear, the benefits are well-defined
and internal resources are supportive of the process.
• As a future vision, Parkland should begin to consider the possibility of a
combined revenue cycle process with the Medical School. Parkland and the UT
have a joint and vested interest in a single medical chart and are billing for the
same patient. Economically, the shared function would reduce the overall costs to
both organizations and ultimately ease the operational issues regarding access to
the medical chart and sharing of eligibility information of the patient population.
Overall Opportunity
The financial benefit to the issues discussed in this assessment should exceed $6 million
and would likely approach a range of $7 - $10 million. Additional benefits exist within
the system but may not have been included due to an inability to support the issue with a
valid quantification.
Process Impacted Goal Opportunity

• Convert patients to • Convert approximately • $4 - $5 Million
funded source $20M additional gross Net
charges
• Collections area • 10% - 15% reduction in • $1 - $1.5
including denials approximately $10M in Million
FY04 denial write-offs
• Time of service • Increase clinic related • $1 - $1.5
collections TOS collections by Million
raising performance to
internal best performers
• Self-pay collections • Goal in place is to double • $.5 – $1
via vendor current collections, this Million
goal is more conservative
Other improvements that would lead to gains include the collecting better information
during the registration process. This responsibility is shared by staff from outpatient
services, COPC, and PFS. This process would assist in Parkland managing the out of
county care issue. An opportunity exists to improve Pharmacy billing for patients that are
given Medicaid retrospectively.
2
Convert More Patients to Funded Sources
Parkland attacked this issue in FY 01 when collections equaled $196,000,000. Today,

collections exceed $300,000,000. This gain was the result of significant focus on the
eligibility process and financial counseling.
Seventy-plus percent of inpatients have funding from a third party. Approximately forty-
eight percent of outpatients are similarly funded. Part of the difference is because
deliveries on the inpatient side are eligible for Medicaid. Outpatient benefits are not as
generous.
Investment in the Front-End Processes
$350,000,000
$300,000,000
$250,000,000 Medicaid increases due to

eligibility amounted to
$200,000,000 half of this increase. Other
$150,000,000 improvements have led to
other payer increases.
$100,000,000
$50,000,000
$-
2000 2001 2002 2003 2004
Cash Collections
The question becomes whether or not Parkland has hit the ceiling regarding converting
more patients to a funded source. Consensus is no. In order to improve on current levels,
additional process and technology changes must occur.
In addition, PHP must not be viewed as a funded source. It is not for reporting purposes;
however, observations and interviews outside of PFS suggested a perception that PHP
somehow generated cash. PHP patients do account for a large portion of time of service
collections, but the remaining bill is written off. PHP must be a last resort.
• Parkland needs the ability to better manage the enrollment process in Medicaid
and PHP. Currently, a system is in place to handle eligibility screening; however,
it is not used all the time and it is not utilized to manage the eligibility case. The
change relates to using the existing or similar application on the market in all the
enrollment occurrences. As a result, Parkland would have more control over the
process, hold the eligibility vendors to a stated performance, possibly reduce
reliance on the vendors, and have a repository of information to help make better
decisions regarding that patient population.
3
• Parkland currently has address verification software but needs something to
improve their ability to match names and addresses to verify residency. An
investment in this area is necessary and may be available first quarter of 2005.
• Parkland should create a policy that promotes community awareness of the
patient’s obligation to participate in the financial funding process. All patients
have the ability to participate in Parkland’s eligibility process regardless of their
ability to pay. This does not mean Parkland would turn away patients that cannot
pay, but rather might delay or defer non-emergent visits for patients that have not
participated in the process.
• Parkland has considered in the past and should consider again a change to the
PHP eligibility criteria. Currently, if a patient declines coverage of any kind at an
employer, the patient is turned down for PHP coverage and is classified as a self-
pay patient. A test related to the percentage of insurance cost to income should be
incorporated into the PHP eligibility process. Rising medical premiums have
made the choice of coverage that is available to some employees a non-choice.
This recommendation is made under the assumption that today’s patient cannot
pay for care regardless of financial classification. PHP allows that patient to
define a level of contribution. There could be significant cost implications to this
type of policy and should not be considered without further economic study.
• Parkland should work with Federal authorities to bring SSI resources to the main
campus. Some patients that could qualify under SSI criteria may not be making to
the SSI offices for completion of the process. The easier the process, the more
participation Parkland should expect.
• The eligibility process cannot be performed without the patient and information
from the patient. Parkland must take advantage of the opportunities when the
patient is engaged in the process such as the scheduling process. Combining the
scheduling process with other data collection would significantly streamline the
verification of insurance process. At a minimum, this could be done for those
patients that do not require clinical intervention in the scheduling process.
• Parkland will not know when the eligibility ceiling is met until they work more
closely with other public facilities and understand their experiences. Currently,
Parkland compares favorably in third-party funding percentages. This comparison
was made with publicly available information. Parkland and the other healthcare
districts could benefit from working together more closely.
• Parkland must begin to set behavioral expectations for the patient related to their
financial obligation. One way to begin is to create consequences for any patient
that is misrepresenting information to gain access to the tax-supported program.
This effort should be directed by legal. Policy should be adopted that directs a
front-line person on how to respond when they believe fraud has occurred.
Parkland might even consider a person whose sole function in to review accounts
for information that is misrepresented.
4
Conversion of Original Financial Classification of Self-Pay to Others on a Monthly Basis
$30,000,000
$20,000,000 For example, June

04 efforts transferred
$10,000,000 nearly $27M from
self pay into the
$0
October November December January February March April May June July
following: $16.8M
into Medicaid,
($10,000,000)
$6.8M into charity,
and $3M into
($20,000,000)
commercial.
($30,000,000)
($40,000,000)
Self Pay Charity Medicaid-Traditional Medicaid Managed Care Commercial Insurance
Laser Focus on Collections

The collections process is not broken. The recommendations are focused and do not
require a wholesale change in the process. The largest opportunities in the back office
collections area relate to denial management, collection strategies, and outsourcing the
low dollar accounts.
• The proactive management of denials should be a priority in the short-term even
before the new technology advances. Although denials are received in the PFS
area and write-offs are ultimately processed in PFS, the reasons for denials are
most often generated upstream in the revenue cycle. Denials must be an
organizational issue and not only an issue identified with PFS.
Top Reasons for Medicaid Write-offs from Denials
(October 2003 – July 2004)
$1,200
No Precert
$1,000
Past filing/Not updated
$800
Missing coding element
$600
Past filing/No Followup
$400
Past Filing/Medical
Records
$200 Past filing/Never Billed
$0
5
One significant denial reason that is not reflected on the chart above is medical necessity
denials. This chart only included the largest Medicaid denials, but more than $500,000 of
write-offs have been recognized for unsupported medical services based on admission
criteria.
• The cumulative amount of write-offs for the prior twelve months exceeds $10
million. PFS, as the “owner” of denial information, must implement an improved
method for involving other key stakeholders that impact denial levels. Once way
to accomplish this would involve communicating more concurrent denial
information. Currently, write-off information is shared across the organization.
Denials need to be shared as they are received.
• The collectors are divided by payer, by account age, and by balance. We
recommend a different stratification of accounts first by balance, with some
collectors working the highest dollar accounts across all payers. Second, accounts
within certain dollar limits would be distributed by payer and then by age. Third,
some collectors would be dedicated to resolving denials within certain payers.
• Accounts under a certain dollar value should be outsourced regardless of payer.
This would likely include a significant volume of outpatient accounts since they
tend to be lower charges. This would likely include all of COPC since virtually all
of their accounts are lower dollar balances. Parkland should accelerate this
process.
Billed A/R Trial Balance
Dollars Volume
$0 - $250 $ 10,195,195 2.9% 205,952 65.1%
$251 - $1,000 $ 32,907,248 9.3% 63,068 19.9%
$1,001 - $2,500 $ 41,406,850 11.7% 26,158 8.3%
$2,501 - $5,000 $ 31,130,103 8.8% 8,849 2.8%
$5,001 - $10,000 $ 43,614,045 12.3% 6,068 1.9%
Over $10,000 $ 194,990,977 55.0% 6,339 2.0%
$ 354,244,418 100.0% 316,434 100.0%
If you exclude self pay from these totals, you would subtract approximately
$211,000,000 and 27,000 accounts from the accounts over $1,000. Self-pay accounts are
not collected internally by Parkland staff. Additional analytics should be developed to
determine the appropriate dollar value for cutoff of outsourcing. An outsourcing partner
should not cost Parkland more for the same or less performance.
• In addition to outsourcing the low dollar/high volume accounts, a concerted effort

to clear the trial balance for both PMAS and COPC/EPIC of old and less viable
accounts should be undertaken. This can mean giving the accounts to someone
else to provide a last attempt at collection. The intangible gains from cleaning up
the trial balance and outsourcing the low dollar accounts that are not prioritized
anyway should lead to greater focus on the remaining accounts and more ability
to focus on impacting issues upstream in the revenue cycle.
6
Clinical Involvement
Perhaps the greatest gain to the revenue cycle exists in enlisting the physician and clinical
staff in a broader participation in the financial processes at Parkland. The clinical staff
can be the best collector. The patient responds well to direction from clinical staff.
Patients must understand the value of services they receive. Today, a patient that drives to
Parkland and parks must pay for parking. If they eat on the campus, they must pay for
food. However, a patient that participates in PHP cannot be denied care or
pharmaceuticals if they cannot pay. The competition for the same wallet dollars is a real
issue and Parkland must get their share of those dollars.
This is another issue that would be impacted by a single voice relative to how Parkland
should deal with the financial obligations of the patient. A registration clerk must expect
to be supported throughout the administrative organization when a patient complains
about a legitimate co-payment or contribution that is requested at the time of service.
• Parkland, physicians and the clinical staff must mutually embrace the fiduciary
responsibility Parkland has to the local taxpayer to maximize the possible revenue
stream while recognizing the sensitivity of the mission of public healthcare
• As mentioned, medical records is a vital function along the revenue cycle.
Parkland must own and control the medical record. This means that Parkland
should use the Medical Record for coding before it is used by others. If other
demands on the chart are required, the chart should be checked out from Medical
Records. Tracking software should be implemented to be successful.
Build Single Accountability
Organizational challenges facing Parkland are significant. We did not observe an overall
belief by clinical service lines that functional process owners could provide adequate
service levels. For example, traditional parts of the revenue cycle, such as
access/registration personnel are not entirely part of the revenue cycle organization.
Financial counseling is not entirely part of the revenue cycle. In fact, Patient Financial
Services registers only about one-third of the patients across the organization.
There are reasons other than the service level issues; however, it appeared as a central
theme throughout conversations. For example, over time, the specialty clinics have
integrated the registration process with so many other support functions within the clinic
that it would be very difficult to carve out registration from the other responsibilities.
For the patient, there are more touches and referrals than necessary with a fully integrated
registration and admission process. The Patient Support Center would have lessened this
issue. This initiative should continue with full attention and should consider incremental
steps towards the end goal. There are points of integration possible without the full
complement of technology and space the entire plan was designed to require.
7
Example of Funded Patient Access Experience
Initial Point
of Entry
Patient gets appointment at COPC and is screened by the Financial Counselors and registered
#1 by COPC (TOS collections by COPC)
Patient is referred to OPC for follow up visit. A funded patient should be pre-registered by
# PFS and then upon arrival will be registered by OPC staff.
Patient has emergent situation and goes to emergency department for care and is registered
#3 by PFS.
Patient is admitted for inpatient stay and may seen by financial counselors from PFS and payer
#4 be specialists from Care Management.
Patient could easily been seen or called by 8 different people

from 4 different departments for just the revenue cycle related processes
COPC OPC PFS Care Management
• One possible process of integration relates to patients that do not require clinical
intervention when scheduling a specialty clinic appointment. For those patients,
perhaps the appointment and funding verification process can occur at the same
time. Parkland has already identified the 21 data points that should be gathered at
the time of scheduling. This would significantly streamline the process of trying
to get the information from the patient after an appointment is made.
Registrations by Area
Area Number of Registrations
Specialty Clinics ≈ 240,000
COPC ≈ 385,000
PFS (ER, Main, Women’s) ≈ 380,000
Quality of the registration is difficult to compare without significant chart auditing which
was not performed for this assessment. However, there are some indicators such as time
of service collections, available information at the time of registration and the
environment of the registration that can be noted.
Total Time of Service Collections by Area (Across all Payers)

(FY 2004 annualized after 9 months)
Area Total Collections
Specialty Clinics ≈ $1.5 Million
COPC ≈ $2.0 Million
PFS ≈ $6.8 Million
Note: These numbers exclude pharmacy collections.
Additional Observations
8
PFS COPC Specialty Clinics
• Large collections from • High degree of focus on • Higher clinic visit prices may lead
repeat patients with prior time of service to higher averages in self pay
balances or previous bad collections category
debt (approx. $3.0 • Integrated into site • Most often patients are referrals for
million) performance metrics COPC or other campus experience,
• ER is difficult which is good they should already have a basis
environment in which to • Medicaid cash is for registration
collect given EMTALA, tremendously higher
plus the competition for evidencing improved
the wallet is high, focus eligibility and collection
less on speed and more processes
on data validation
Ultimately, to attempt a reorganization of registration would be too disruptive to the

organization. However, if Parkland were to consider adding FTE’s to the front-end
process, the campus outpatient clinics would be a good place to implement a dedicated
registration position. In addition, continued focus on always improving the ER process of
registration with appropriate technology to support the registration is always an area of
focus.
Despite the lack of overall ownership, PFS should provide a standard expectation for the
registration. Today, PFS meets with COPC and OPC to discuss issues and communicate
any regulatory changes to the process.
• Since the clinical areas own their own registration process, they must be open to
participate in any initiatives raised by PFS as crucial to the other parts of the
revenue cycle. Particularly, this should include denial management related
initiatives since many of the issues that lead to denials can be caught in the initial
registration process.
• Other organizational issues include the integration of the payer specialist position
into financial counseling. This is overlap in the goal of this position and the
financial counseling role. Discussion should occur regarding financial counseling
to oversee this process.
• Also, Medical Records, a key component of the revenue cycle should reside in the
same chief leadership structure as PFS. Experience suggests that when two areas
share considerable parts of the same overall process, one single and accountable
leader can affect change better.
• Finally, Parkland contracting for reimbursement by third-party payers should be

consolidated within one office. In addition, the approval process should be
streamlined so revenue generating changes to contracts can be approved without
administrative delay.
Other Issues
9
• Although only a brief conversation occurred, Medical Records appears to need a
focused review that will bring sustaining improvement to the processing of charts.
Recent involvement by third parties have only addressed backlogs and achieved
one-time benefits that have not sustained themselves.
• There are significant challenges with calculating an accurate patient services net
revenue amount on a monthly basis. Despite the difficulties, the accounting
department must work diligently towards recognizing net revenue based on a
consistent methodology rather than booking cash as net revenue. It is impossible
to measure success of cash collections versus net revenue using the current
method. This issue is linked to reserving methodology as well.
• Parkland has access to a tremendous amount of data. This can be good and bad.
We found it difficult to decipher all the different data even when two different
reports were covering the same issue. For example, days in receivables are
calculated differently across the organization. There should be a consistent
methodology for each data point, service line, etc. that is agreed upon and
communicated consistently throughout Parkland. There is a commitment to the T-
2 system by decision support and accounting and everyone across the campus
should work with the same data and define reports the same way. There has been
progress during the past year to achieve these objectives. Accounting must work
closely with PFS, particularly since cash has such a significant impact on how
revenue is booked.
• Work with new technology to implement a process for deployment of software to
generate ABN’s. Parkland must address this issue to better inform their Medicare
patients.
Prioritization
One of the recommendations we have made is for Parkland to focus on a few things to
completion. There are many constituents internal and external to Parkland that help set
priorities. Senior management must help staff to stay focused on a well-defined plan of
attack.
1.
Complete the technology implementation June 2005
2.
Define, agree and publish next years goals 30 days
3.
Low dollar outsourcing of accounts (COPC/other) 60 – 90 Days
4.
Assistance for Medical Records (not PFS decision) ASAP
5.
Trial balance clean up for EPIC/COPC and PMAS 12/31 solution
6.
More proactive approach to denial management Ongoing
7.
Research and implement technology to support
demographic validation of patient information Q1 2005
8. Work with physicians and clinical staff on
participation in eligibility and funding process ongoing
9. Integration solution to enrollment software 12/31 solution
10. Research the annual contribution for PHP concept TBD
Summary
10
PFS has experienced tremendous growth in cash collections over the past four years.
During that time, PFS has gone from collecting $196 million to over $300 million. For
the first year since FY 2000, cash collections are relatively flat. Some of the issues are
quantifiable. It is estimated that the Medicaid changes alone to rates and coverage levels
have led to at least $20 million less cash for FY 2004. Combined with the shifting patient
population from inpatient to outpatient, Parkland has experienced a significant cash drain
from just two sources. Increases in COPC and Medicare collections helped cut into those
reductions.
We found PFS management to have a firm understanding of the issues that need
attention. We have discussed the recommendations, quantifiable opportunities, and
thoughts regarding prioritization. There is acceptance by PFS management of the issues
discussed.
There are other opportunities that will produce financial wins that are not easily
quantified and were not included in the opportunity schedule. For example, an
opportunity for pharmacy to bill Medicaid when eligibility occurs after the script has
been written or an opportunity to interface a part of the lab system that may have dollars
that can be re-billed retrospectively. Perhaps a charge capture program that appropriately
captures charges would result in a true reflection of the cost structure supporting the
services provided and raise the UPL opportunity. These opportunities should not be left
behind while planning continues for 2005.
Since many of our recommendations do not focus entirely on PFS’ internal operations,
the revenue cycle will need significant senior management support to achieve the gains.
For example, the single voice of how to deal with the patient’s financial obligation and
the physician staff assisting in the financial counseling/eligibility process by encouraging
the patient’s participation are issues that PFS cannot attack without support.
The best approach to all these initiatives is to define the objectives well, the performance
measures for success, and resource the initiative appropriately with the right stakeholders
involved. If this is done, Parkland has a better chance at success to achieve the goals set
forth in this document.
11
COPC Assessment Report
Health Management Associates
Primary Care
Parkland was one of the first public hospitals in the country to establish a Community
Oriented Primary Care (COPC) system of clinics in communities with high, unmet
healthcare needs. These needs were inappropriately utilizing the emergency department
for health care that could be more effectively provided in a decentralized primary care
system. Parkland understood that an integrated system of care must shift the emphasis in
healthcare delivery toward primary and preventive care to provide the most appropriate
level of care for its patients.
The COPC system currently consists of: seven community-based clinics, the Ambulatory
Care Center (ACC) providing urgent care on-site at Parkland, employee health, campus-
based clinics for geriatrics and pediatric primary care, ten Youth and Family school-
based clinics, and a homeless program (HOMES). Collectively, these facilities deliver
327,485 adult, geriatric, pediatric, and behavioral health visits to approximately 121,872
patients annually.1
In addition to the COPC network, the Parkland system operates eight sites offering
prenatal and other women’s health services through the WISH clinics in partnership with
the University of Texas Southwestern School of Medicine. Five WISH clinics are
located within the COPC clinics and three are independently housed. In 2003, these eight
WISH sites provided 98,129 prenatal and women's health visits. Finally, two residency
training primary care clinics (internal medicine and family practice) operate at Parkland
hospital and provide another 22,297 and 10,971 visits respectively. 2
The COPC sites offer the full range of primary care services for children, adolescents,
adults, and geriatric patients. These services include well child checkups, routine
physicals, treatment of acute and chronic health problems, immunizations, behavioral
health, nutrition counseling, cancer screenings, HIV/AIDs testing and counseling, health
education (smoking cessation, diabetes management, etc.) pharmacy, lab and x-ray
services.
Although there is no reliable income data on COPC patients, approximately 40% of those
seen in the COPC clinics are uninsured and 39% qualify for Medicaid or the State’s
SCHIP program, with the remainder of COPC patients covered by Medicare or other
funding. The COPC patients are heavily Hispanic and African-American (46% and 36%,
respectively). About half of the patients are children under the age of 14, 43% are
between 15 and 64 years old, and 6% are over 65.
1
Does not include EPO (Parkland employees).
2
FY2003 Service Line Analysis with fully allocated costs. PHHS
Health Management Associates Appendix K-1

Southwestern Obstetricians and Parkland midlevel providers staff the WISH clinics. The
WISH clinics offer prenatal care in addition to women's health visits. The medical
records of all prenatal patients are located at Parkland Hospital to enable efficient access
for labor and delivery. After delivery, discharge appointments for the women and
newborns are made electronically at COPC and WISH sites. There are also Family
Planning clinics located within COPC and WISH at five sites.
The patients seen at the WISH clinics are predominately Hispanic (80%) and uninsured
(82%). However, it should be noted that once these prenatal patients deliver their babies
at Parkland, their payor status changes and nearly 90% become eligible for Medicaid
coverage. Thus, an investment in prenatal care results in paying patients for the hospital.
Youth & Families and Dallas Independent School District recently received a presidential
recognition for its integration of mental health and medical services. The Youth &
Family school based sites are located on public school grounds, and are accessible
throughout the year. Hours are generally Monday through Friday 8am-5pm, plus evening
hours at three locations. The school district provides mental health services and Parkland
offers medical services and a Class D pharmacy. Three sites also see adults from the
surrounding community. Each school-based site is linked with a COPC clinic for
referrals for lab, x-ray, and other services not offered on site. Pregnant students are
referred to a Parkland WISH clinic for prenatal care.
ACC (urgent care) serves adult walk-in patients who are sick and/or have long-term
chronic illness and 80.3% of the patients are uninsured (charity and self-pay patients).
Some patients are referred to ACC when they are discharged from Parkland (and other
hospitals) and 12,153 visits (25% of total) were directly referred from the Parkland
Emergency Department in 2003.3
The HOMES program is a Federally Qualified Health Center (FQHC); a federally funded
Section 330(h) Healthcare for the Homeless grant program operated by COPC. In 2003
HOMES received $1,018,872 in grant funds (baseline award that is annually dispersed) to
support and staff three customized mobile vans, that provide services at 37 clinic sites
around Dallas County each week and provided services to 5,009 homeless patients in
2003.
The COPC, WISH, and Youth and Family clinic sites are located in areas that have
significant pockets of low income people (below 200% federal poverty), in
neighborhoods that do not have enough primary care providers, and in zip codes with the
heaviest utilization of the Parkland Emergency Department and Children's Emergency
Department. (For detailed documentation, see Appendix K-2.) Detailed COPC clinic
profiles for the seven community based sites are provided in appendix K-3. Each profile
contains current COPC patient data and the demographics and health status of the
community it serves.
3
Department of Emergency Services Monthly Statistical Report, 2003-2004

COPC Providers and Programs
COPC is involved with community-based organizations, churches, youth programs, and

other local institutions, relationships that are sustained by COPC's community workers.
As the most visible face of Parkland in the local communities, they work closely with
ministers and local leaders to organize COPC Advisory Boards, immunization drives, and
back to school health fairs. Such a high level of community involvement visibly
demonstrates to local taxpayers that COPC and Parkland are attempting to address the
health needs of their neighborhoods.
Over the years, COPC has expanded its services to include more health education and
prevention, behavioral health, child development, and more referrals to social service
agencies. The federal government requires these "wrap around" services before
designating FQHC status (cost based reimbursement) or providing section 330 grant
funds, a HMA recommendation for the COPC sites. After 35 years of operating the
community health center program, the government has documented that these services
are essential, and would otherwise be inaccessible to vulnerable populations.
Historically, COPC has implemented innovative clinical programming, most recently by

becoming one of the first public institutions to test the Shared Medical Appointment
(SMA). A SMA involves a group of similar patients (newborns, adults, etc.) agreeing to
a 90 minutes group session with a physician, social worker, RN, and pharmacist. Patients
arrive early to have their vital signs taken and the doctor interacts with each patient in the
group setting, exposing everyone to the interaction/education. A patient may also request
to speak privately with the doctor, social worker, or nurse at the end of the session.
COPC was interested in this type of clinical session to reduce wait times and increase
access to its sites. Patient surveys reveal very high levels of satisfaction. COPC and
Parkland will undoubtedly continue to offer innovative clinical programming.
All COPC services, (including Youth & Family, HOMES, ACC, support staff for COPC
based pharmacies) were provided by 143 FTE medical providers, 25.65 FTE mental
health workers, 196 FTE nurses and medical assistants, 256 FTE business and clerical
staff, 18 FTE language assistants and 5 FTE community workers. COPC physicians are
directly employed by Parkland. The pediatricians are on faculty at Children’s Medical
Center and pediatric residents rotate through three COPC community based sites,
supervised by COPC employed physicians. (For breakdown by site and provider type,
see Appendix K-5: COPC Staffing Tool June 2004)
Staffing & Productivity
The federal government sets minimum productivity standards for the providers who
practice in Federally Qualified Health Centers (FQHCs) and this standard serves as a
rational benchmark for similar health care facilities. The COPC clinics, as a system, fell
short of those minimum standards for physicians in 2003, although they met the standard
for mid-level providers (nurse practitioners, for example). This doctor productivity level
caused concern among the Parkland COPC administration and an effort has been

underway, through an intensive team model, to improve this indicator. By the period of
March through August of 2004, the annualized number of visits per physician had
increased from the 2003 rate of 2,794 visits/doctor to 3,484, still under the minimum
federal level of 4,200 but clearly significant progress has been made.
Providers BPHC FY 2003 COPC March-Aug 2004

benchmark baseline visits Annualized Visits
Physicians 4,200 2,794 3,484
Mid-level providers 2,100 2,568 3,125
Source: BPHC and COPC Administration
(See Appendix K-4: Operations Plan Performance, for monthly provider targets and average visits March -
August 2004.)
A team of administrators and clinicians established the Care Team model in March 2004
to accomplish this improvement. These Care Teams were comprised of a clinical
provider, nurse and business support person. Clinical visits and financial goals were
established for each Care Team based upon the type of provider (pediatrician, internist,
nurse practitioner, etc.) and his/her administrative responsibilities, paid time off, and
continuing medical educational requirements. Each individual team had quantifiable visit
and cash collection goals established.
The Care Team success will be taken into account for each COPC staff member's annual
evaluation (worth 50% total) beginning this year. The clinical providers and business
office staff are attempting to maximize clinical productivity, without compromising the
quality of care. A group of physicians will be evaluating whether the quality of care has
been maintained as productivity starts to increase.
Greater productivity by COPC providers is critical in meeting the increasing demand for
services, particularly for chronically ill adults. If patients cannot get appointments in the
COPC clinics, they will likely seek care in the Emergency Department (ED). According
to FY2003 Service Line Analysis figures, the average cost per COPC visit is $90 while
the average ED visit is $163. It is clearly valuable to the system to keep as many patients
in the clinics as possible.
In FY2003, the COPC clinics had the staff and physical space capacity to provide
116,340 adult and geriatric visits yet they actually provided only 92,413 visits in that
category. The productivity efforts to date in 2004 have them on target to come closer to
their available capacity.

Adult and Geriatric Capacity
FY 03 Monthly COPC Monthly March-Aug 04 Available
Site Average Visits Visit Target 2004 Monthly Capacity
Average
Bluitt 1,615 1,904 1,952 (48)
DeHaro 1,272 1,537 1,518 19
East Dallas 1,660 2,002 1,884 118
Garland 1,066 1,672 1,514 158
Oak West 220 216 447 (231)
Southeast 1,868 2,364 2,124 240
TOTAL 7,701 9,695 9,439
Annualized 92,412 116,340 113,268
Source: COPC Administration
Across the seven COPC community clinics, the school-based centers and the pediatric
clinic on campus, there is additional capacity at current staffing levels, for approximately
2,300 visits per month, according to the COPC productivity benchmarks listed in the
table below. There has been an improvement since 2003 when there was capacity to
provide additional 35,000 visits. As children are most likely to be covered by Medicaid
or SCHIP it is a system priority to increase pediatric visits.
Pediatric and Adolescent Capacity

FY 03 Monthly COPC Monthly March-Aug 04 Available
Site Average Visits Visit Target 2004 Monthly Capacity
Average
Bluitt 1,256 1,545 1,158 387
DeHaro 2,271 2,717 2,096 621
East Dallas 1,893 1,950 1,907 43
Garland 1,210 1,248 1,442 (194)
Oak West 932 1,014 864 150
PPCC 892 1,139 936 203
Southeast 1,289 1,572 1,313 259
Vickery * 608 1,010 901 109
Y& Family 1,491 2,628 1,972 658**
TOTAL 11,841 14,823 12,588
Annualized 142,092 177,876 151,056
Source: COPC Administration
* Family Practice ** school was not in session 3.5 months
Most of the 16,000 babies born at Parkland do seem to keep their follow-up appointments
at COPCs but it is unclear whether these children stay in the system. Further, the
Parkland Community Health Plan, its Medicaid/SCHIP managed care entity, could be
assigning larger numbers of children to the COPC sites. In August 2004, there were a
total of 37,042 Parkland Community Health Plan members assigned to COPC sites, less
than half the total health plan enrollment. This would be an additional opportunity to
increase pediatric utilization.

COPC administrators have already utilized the data above to make decisions about
shifting Care Teams between the sites. Recently, to fill vacancies at Garland and
Vickery, two pediatric Care Teams were relocated from Bluitt Flowers where demand for
pediatrics had fallen. We encourage the additional reallocation of resource by taking a
closer look at DeHaro pediatrics, which has tremendous excess capacity. COPC takes
accountability very seriously and has not ruled out staff reductions in under-performing
sites and/or Care Teams. (For the Care Team Roles and Financial Management Tool, see
Appendix K-4.) The COPC leadership is to be commended for launching this effort and
its success will rely on constantly monitoring the data and making difficult decisions.
It is also important to evaluate other potential factors that may be adversely affecting a
site's productivity beyond individual provider benchmarks and community demand.
When we evaluated the number of exam rooms per provider at each COPC site, the sites
with the highest ratios (Southeast at 2.66, DeHaro at 2.67, PPCC at 2.67 and Bluitt at
3.25) also had the lowest productivity. This is interesting because large public systems
are traditionally unable to maintain a ratio of 2 exam rooms to 1 clinical provider, thus
limiting a provider's capacity to maximize his/her time seeing patients. Since this is not a
problem at some of the COPC sites, we must look elsewhere to evaluate productivity
levels. Across all COPC sites, we evaluated staffing ratios by making a comparison to a
commonly utilized benchmark established by Medical Group Management Association
(MGMA) an organization representing over 237,000 physicians.
Ratio MGMA COPC

Mean
Support staff FTE per physician 5.29 6.48
RNs & Medical Assistants per physician 1.34 1.37
Business and clerical staff 2.09 1.79
Medical Group Management Association, 2002
On average, the COPC provider to support staff model is in line with MGMA. However,
COPC is higher when total support staff is compared. Business and clerical staff in a
private physician office may be higher because COPC does not do its own billing, staff
that are not included in table above. (Appendix K-5: COPC Staffing Tool June 04,
MGMA 2002 Benchmarks.)
We encourage COPC to continue to assess its staffing ratios as they carefully evaluate
their cost structure. Recently, COPC discontinued its reliance on a nursing registry for
coverage during vacations and other paid time off. They have also decreased float staff
and are implementing the seasonal paid time off option at selected sites offered by
Parkland Human Resources.
As previously mentioned, the average COPC cost per visit is $90 (ACC urgent care $110)
while the average Parkland ED cost per visit is $163. The best way to lower these costs
even further is by increasing provider productivity. As the low income and uninsured
population continues to increase in Dallas County, the long term sustainability of the
COPC system becomes critical to maintaining the health status of this population, and

maintain the ability to operate a cost effective delivery system for Parkland and Dallas
County as a whole.
Patients
In 2003, COPC sites (excluding ACC urgent care and Parkland employees) provided
services to 121,872 patients (58% female/42%male). There were slightly more children
than adults, with very few adults over the age of 65.
COPC Patients by Age* Unduplicated Patients % Total % Female

Under age 5 38,968 32% 51%
Ages 5 - 14 22,789 19% 51%
Ages 15 - 44 28,311 23% 66%
Ages 45 - 64 24,089 20% 69%
Ages 65 and over 7,715 6% 71%
TOTAL 121,872 100% 58%
(*Does not include ACC or Parkland employee site. See Appendix K-3: Community Clinic Profiles)
COPC does not keep income data on its patients. Yet when reviewing patient payor
sources, we note that approximately 40% are uninsured and 39% qualify for Medicaid
and KidsFirst (state/federal funded program for low income families) for a total of 79%
participating in programs designed for low-income families.
By analyzing charges and volume by revenue code at the largest COPC sites for the
month of March 2004, we were able to document that 62.7% of all COPC pharmacy
usage was by Charity patients or those in Parkland Health Plus (PHP) program for the
low-income uninsured patient. Additionally, this same group utilized 57% of all clinic
appointments. This is interesting because there are 41,701 COPC patients (49% of total)
between the ages of 15-64, and the typical profile of a PHP patient is the uninsured adult.
This leads us to speculate that it is the PHP patients that are utilizing COPC resources
disproportionately, especially pharmacy, an indication that this population suffers from
chronic illnesses.
According to a National Research Corporation annual Dallas County survey of healthcare

utilization and prevalence of chronic conditions conducted in 2001, the top diagnoses at
the COPC clinics are consistent with prevalence rates for Dallas County. Hypertension is
the number one adult diagnosis at every COPC site followed by type II diabetes and
urinary tract infections. Others in the top ten include asthma, allergies, ear infections, flu,
viral infections, and depression/psychological stress. These conditions are similar to
other health status measures in Dallas County. Dallas County residents reported that
28.6% of them suffered from hypertension, 25.3% high cholesterol, 15.5% asthma, and
11.1% diabetes.
It is this older age group that tends to have chronic diseases and utilize more health care.
A disease management program designed to improve the health of persons with chronic
conditions will, ultimately, result in cost savings. It is the Parkland Health Plus

population that may benefit the most from a disease management approach, and we
would recommend utilizing COPC as the platform for implementation.
Operations and Policies
COPC has a Vice President of Operations, who is responsible for the oversight of the
COPC clinics. A Resource Team comprised of twelve director and associate director
level positions, including the Medical Director, Behavioral Health Director,
Operations/Finance Director, among others, report directly to her. However, she also
directly supervises the nine site administrators that oversee clinical services and
operations at each site. In addition, each site has a Lead Physician and Lead RN. The
COPC Medical Director does not have any direct supervising authority over the Lead
Physicians.
Most of the community based COPC sites have Community Advisory Boards. These
were established when Parkland recognized the importance of community involvement
and input into its clinic system. Historically, the Advisory Boards have brought
community needs to the attention of COPC. For example, it was the Advisory Boards
that raised a community concern regarding the injury rate of children in automobile
accidents that resulted in the development of a COPC car seat distribution and car safety
education program. Recently the Advisory Boards have felt some frustration with the
COPC administrative focus on improving the point of service cash collections. They
worry about this policy’s adverse impact on obtaining access by deterring uninsured self-
pay patients from returning for services. The WISH clinics, for example, do not charge a
co-payment for prenatal services to encourage early access to prenatal care.
COPC's finance and eligibility staff report to the COPC leadership (instead of Parkland's
financial operation). Approximately two years ago, a concerted effort was organized to
improve eligibility screening for COPC patients to enroll them in Medicaid and other
benefits for which they may qualify. Uninsured patients seeking care are required to
enroll in Parkland Health Plus before obtaining services. At the same time, collection of
co-payments for self-pay patients is now more strictly enforced. This has resulted in
increased cash collections at COPC sites and some believe it has the perverse incentive of
motivating some patients to go to the Emergency Department and ACC (where collecting
co-payments in an emergency prior to providing a health service is illegal) instead of
seeking primary care to avoid acute episodes. COPC and Parkland may want to review
the impact this policy has had on the health seeking behavior of its patients.
The COPC appointment function is moving towards a centralized system. HMA heard
conflicting reports on appointment availability and accessibility. According to COPC, a
new pediatric patient can receive same day or next day appointment. For adults, they
indicated it might take 6 to 8 weeks to obtain an appointment as a new patient. The
COPC Advisory Board focus group insisted that it is very difficult to obtain an
appointment. To document the experience firsthand, we attempted to obtain
appointments for both an uninsured new pediatric and new adult patient. It proved
difficult for us to obtain any appointments at the clinics. In short, we were only able to

obtain an appointment for the child and the appointment clerk stressed the importance of
being screened for Medicaid eligibility. At one site, the new adult patient was told to go
to the unemployment office to get letter documenting employment status (if unemployed)
and come in to the clinic and enroll in Parkland Health Plus prior to receiving an actual
appointment, after which an appointment was not be available for 2-3 months. Another
COPC clinic said they would mail the patient an appointment when one became
available, and that all appointments were taken that month.
Access to care is also affected by the hours a site is open. Most COPC sites are open
Monday through Friday opening at 7:30am or 8:00am and close at 5:00am or 6:00pm.
ACC (urgent care) is open seven days a week from 8:00am - 8:30 pm. DeHaro is opened
on Saturdays from 8:00am - 6:00pm and Vickery operates urgent care hours on Sunday
from 8:00am - 6:00pm.
Relationships
Another barrier that interferes with continuity of care for Parkland patients involves the
use of two information systems, one for on campus and one off campus for COPC sites.
This becomes problematic when COPC patients go to the Emergency Department
because the ED is unable to establish whether the patient receives their primary care
within the Parkland system, both to obtain data on the patient and also to make a follow-
up appointment upon discharge. The same is true for ACC (urgent care) even though is
part of the COPC system.
The COPC physicians are directly employed by Parkland and are not responsible for any
inpatient activity. They have difficulty directly admitting a patient through the
established protocol and often send the patient to the Emergency Department as the most
efficient mechanism to get a patient admitted to the hospital. Unless the patient notifies
the physician, the COPC site is unaware when their patients are admitted and/or
discharged from Parkland.
COPC providers confront long wait times in obtaining specialty and diagnostic
appointments for their patients. There is tremendous demand at Parkland for cardiology,
pain clinic, gastroentrology, dermotology, neurology, and opthamology clinic
appointments.
However, we were able to confirm that COPC newborn appointments are occurring upon
discharge from the Parkland newborn nursery. The chart below summarizes a report
generated by the EPIC electronic appointment system in use by COPC.
EPIC Report Newborn Appointments to COPC: January 2004- August 2004

Regular Follow-up Regular High Risk Follow- High Risk
Appts (6-14 days) Appt's Kept up (within 6 days) Appts Kept
COPC sites 9,000 7,619 325 293
(For newborn appointments made and kept by COPC individual sites, see Appendix K-6.)

Children’s Medical Center relies on the COPC system of clinics, particularly for children
covered by Medicaid and the uninsured. COPC pediatricians believe they have a better
relationship with Children’s Medical Center than COPC physicians have with Parkland.
Most of the pediatricians rotate through Children's inpatient service for two weeks a year.
This appears to have a positive impact on their connection to Children's and on
knowledge about how the systems work. Also, most of the COPC pediatricians were
trained at Children's, so they know many of the physicians there. However, it is often
difficult to obtain timely appointments for specialty and diagnostic services, particularly
immunology, dermatology, MRIs, neurology, developmental assessments, and
orthopedics.
COPC has connections with several other hospitals, most notably, Baylor, and
Presbyterian. Baylor is a contributing partner to the planning and operations of the new
Irving site and Presbyterian provides ongoing financial support to the Vickery site.
Finances
There are inherent limitations on the overall potential of COPC to ever achieve a
balanced budget. In fact, the reimbursement policies of Medicaid and Medicare are
insufficient to achieve such a goal. Moreover, as the number of uninsured adults and
children rises, so does the population Parkland exists to serve. The payor mix of COPC
essentially is 90% dependent upon government reimbursement.4 Overall, the financial
position of the COPC sites result in an annual loss of ($15,594,655) before allocations
and ($29,124,805) after indirect costs and tax/tobacco dollars are applied. It is quite
common for primary care to experience such losses, particularly in public systems with
high numbers of uninsured patients. Nevertheless, primary care is the most effective and
cost efficient level of care to offer.
2003 COPC Financials (in 000s)

COPC (Excluding
Employee Clinic)
Total Gross Charges $40.5
Total Payments $10.1
Cost Report Settlement $2.0
Net Timing Variance Tied to G/L $0.7
UPL $2.7
Total Net Patient Revenue incl. Allocated Patient Revenue $15.6
Direct Cost $31.1
Contribution Margin Before Allocations ($15.5)
Indirect Cost $27.5
Excess (Shortfall) Before Allocations ($43.0)
Tobacco Dollars $0.2
Excess (Shortfall) After Tobacco Allocation ($42.8)
Tax Dollars $13.6
Excess (Shortfall) After Tax Allocation ($29.1)
4
Self-Pay/Charity 37.58%; Medicaid Managed Care 26.60%; FFS Medicaid/KidsFirst 12.65%; Medicare
10.24%; and Other 12.93

It is only by taking advantage of Medicaid and Medicare enhanced reimbursement,
hence, by becoming an FQHC, that COPC may achieve a significantly improved
financial position along with keeping provider productivity improvements on target.
Key Issues
Locations and Size

The location, size, and staffing of clinics does not always align with community need.
Monitoring provider productivity by Care Team, module, site, and community is essential
in achieving alignment between supply and demand. A continuous process of assessing
demand and reallocating resources should be instituted before expansion is considered.
By utilizing the criteria outlined below, COPC can successfully evaluate if and where to
expand.
• Is there a sufficient portion of the population under 200% of the federal poverty
level in the service area to support existing or new clinic, now and in the future?5
• Where is the population accessing care now? Is this an area of high, medium or
low density of Medicaid physicians? Document Emergency Department usage at
PHHS, Children's, and other hospitals.
• Are there potential partners to contribute financially to the capital investment and
ongoing operations?
• To determine the type of providers and services to offer, COPC should document:
o The age distribution trends of the surrounding community.
o Health status of the surrounding population, particularly mortality and
morbidity indicators.
o Analyze the Emergency Department discharge diagnoses of local hospitals
as well as the ambulatory sensitive and preventable conditions
These are questions that should be asked on a regular basis. At the moment, we have
several recommendations to make regarding the need for potential expansion into new
communities and/or relocating or reducing services at existing sites.
Expand into Irving

Irving residents currently rely on COPC for 13,899 visits last year and utilized Parkland
emergency department (9,621 visits), and other outpatient services for 54,497 visits.
Additionally, Irving residents relied on WISH services at two sites, deHaro and Maple,
for a total of 4,615 prenatal visits. The Irving population is increasingly Hispanic and
poor. Characteristics of the segment of the population living below 200% federal poverty
are:
• 55% Hispanic, 25% White, and 11% African American
• 36% age 0-18, 60% age 19-64, and only 4% over 65 years
5
Currently Parkland defines low income as families earning $25,000 or less per year. The federal
government utilizes federal poverty level standards, a methodology we encourage Parkland to utilize.

Hence, Irving has a low-income, aging, and predominately Hispanic population that
access Parkland services already. There have been other partners involved in the
establishment of an Irving site and federal grants and local resources are already secured.
The majority of PPCC's patients live in the northwest quadrant of Dallas County (about
half in Irving) an area that lacks a COPC site. PPCC was started as a newborn discharge
overflow clinic when appointments were unavailable in outlying COPC clinics. The idea
was for initial newborn appointments to occur at PPCC and then transfer the patient’s
care to their local COPC. Last year PPCC had 9,855 visits. Once a COPC site is built in
Irving, it may be possible to significantly downsize PPCC.
Evaluate feasibility of utilizing Parkland owned Kaiser buildings

Parkland owns two empty buildings that are each between 35,000-38,000 square feet and
were previously owned by Kaiser and used as medical office buildings. One is located in
South Oak Cliff and another in Southeast Dallas. The current Oak West COPC site is
small, cramped and operates at capacity. We recommend COPC and Parkland explore
the feasibility of relocating Oak West (with the WISH clinic) to the South Oak Cliff
empty Kaiser building and consider providing specialty and diagnostic services that are in
high demand.
The Southeast Dallas Kaiser building is located in a community that is one of the top ten
zip codes utilizing both Parkland and Children's Emergency Departments. An
assessment of demand for primary care should be conducted to evaluate the worth of
opening this empty site as well. However, the assessment should include a thorough
evaluation of the poorly utilized and underperforming Southeast COPC site. There are
plans to locate a WISH clinic at Southeast and that may help generate pediatric visits, but
there may be a more fundamental underlying problem. One possibility worth noting is
the current building configuration may contribute to lower productivity.
The Youth & Family school based sites have increased the number of students and
community members they see since new leadership was installed two years ago. The
Kiosco site is located in the affluent north Dallas area and serves a population that lives
primarily in low-income apartment complexes, sometimes with multiple families sharing
cramped quarters. This site offers evening hours one day a week and its services are in
high demand. In addition, the Vivian Field site is located in north Dallas near a densely
populated series of additional apartment complexes. COPC does not have a clinic in
north Dallas and these sites have become points of access for the underserved population
in these communities. The Kiosco site could easily offer more evening hours throughout
the week to decrease reliance on the Parkland ED (Kiosco zip code is one of the top 10
highest utilizers of Parkland ED). The closest COPC clinic, Vickery, is also operating
near capacity. Again, the northwest quadrant of Dallas County residing near I 35-E needs
a coordinated PHHS plan to increase access by expanding capacity for this growing
population in need.

Pediatric Patients
One potential source of additional pediatric patients is the Parkland Community Health
Plan, Inc. With almost 70,000 children enrolled in the plan, only 37,042 of these children
selected COPC as the medical home for their primary care, as of August 2004. The
documented need for more paying patients within COPC, particularly children, should
motivate the health plan and COPC administration to work together for the benefit of the
Parkland system. Furthermore, if COPC receives FQHC designation, all of the Parkland
pediatric Medicaid patients, whether fee for service or managed care, will receive cost
based reimbursement, a major incentive to redirect these pediatric patients into COPC
sites. Enhanced reimbursement will also benefit the Parkland Community Health Plan,
but only for those patients assigned to Parkland primary care sites.
Hours
A common strategy to increase access is to expand hours of operation. We recommend
COPC explore the feasibility of expanding hours at the sites most in need of additional
appointment slots. Examples are:
• The Vickery site is one of the busiest sites and operates as an urgent care clinic on
Sundays from 8am-6pm, yet their hours during the week extend only to 5pm.
• Oak West is one of the smallest and most productive sites yet it does not have
evening hours beyond 6pm (and 5pm 2 days a week) or weekend hours.
Productivity vs Staffing
COPC has implemented a major productivity initiative and we encourage COPC to put
equal emphasis on continually reviewing its staffing model and staffing ratios. This will
further refine its operations, help to achieve maximum capacity, and improve access for
the population of Dallas County. Given the patient population's payor mix it is essential
that COPC monitor its cost structure, which is predominately staff, in a primary care
setting.
Medical Leadership
The role of the Medical Director should be reconsidered and expanded within the overall
organizational structure to strengthen clinical leadership and accountability at the top of
the organization, in addition to providing a more direct voice for COPC physicians.
Physician leadership will also be required to implement an effective disease management
program. The physicians will be required to directly report to a Medical Director when
COPC applies for FQHC status.
Operations and Policies

COPC and Parkland should evaluate their cash collection and billing policies and try to
remove any incentives that may motivate patients to seek inappropriate levels of care in
order to avoid co-payments. Currently, the collection practice differs from one type of
clinic to the next. COPC, residency clinics, specialty clinics, and the pharmacy clinics on
campus all differ in their collection practices. The Emergency Department and ACC
urgent care are required to meet Emtala regulations, however, we encourage COPC to
reevaluate their Emtala interpretation for ACC. Working more closely with the ED to

encourage patient follow-up appointments in their community (rather than ACC) should
be improved. However for this to occur, COPC must improve access to timely
appointments for adult patients. Further refinement of the centralized appointment
system for COPC should be a priority. Continued collaboration with WISH, and better
communication at the local site level is encouraged. The goal should be to have policies
and procedures that encourage the health seeking behavior that COPC and Parkland
desire.
Pediatric Partnerships
Expanding the relationship between Children’s Medical Center and COPC is warranted.
Both to improve referral processes between organizations, but also to coordinate and
conduct strategic planning around the primary care needs of low-income Dallas County
children. The same type of discussions must occur with other hospitals and COPC sites,
including Presbyterian, Baylor, Methodist, and Medical City.
Conclusion
The Parkland COPC system has shown real improvement in productivity. We believe
COPC can meet the future demands on its system with modest expansion efforts over the
next few years. By implementing a formal disease management program, making a
serious effort to improve connections both within Parkland and with external partners,
applying for FQHC status and by modifying financial and appointment policies to
improve patient access, COPC can remain a strong asset to the PHHS system.

COPC Locations & 10 Zip Codes with Highest Parkland ED Use
\
Ì
Î
Í
Ì
Î
Í
Ì
Î
Í
6
6
635
63
635
635
3
6335
5
5
5
Garland$
Vickery$75231
75220
Ù
Ú
75
Ì
Î
Í
Î
Í
Ì
Î55
Í
Ì
63
635
63
635
63
75235
PPCC/FMC$ 75228
East$ Ì
Î
Í
Î
Í
Ì
30
30
30
75212
deHaro$ 75227
Î
Í
Ì 30
75215
75211
Southeast$
75216
Bluitt-Flowers$ 75217
Oak West$ ?
Ì
Î
Í
20
Ì
Î
Í
35E Ì
Í
Î
45
Ù
Ú
175
Ù
Ú
67

COPC Locations & 10 Zip Codes with Highest
Children Medical Center’s Use
Ù
Ú
75
Ì
Î
Í
35E
Ì
Î
Í
635
Garland
$
Vickery 75231
75220 $ Ì
Î
Í
635
Ì
Î
Í
30
75061 PPCC/FMC 75228

$
East
$ Ù
Ú
80
75212
deHaro 75227
Î
Í
Ì
30 $
Ú
Ù
80 75208
75211
Southeast
$
Bluitt-Flowers 75216 75217
Oak West $
$ ?
Ì
Î
Í
20
Ù
Ú
175
Ù
Ú
67
Ì
Î
Í
35E

COPC & Unused Site Locations
Î
Í
Ì
35E
35E
Ì
Î
Í
635
Garland
Ù
Ú
75
$
Vickery
$
Ì
Î
Í Ì
Î
Í
30
Ì
Î
Í
Ì
Î
Í
6
635
63 5
35
5
635
63
63
63 55
PPCC/FMC
$
East
$ Ì
Î
Í
Î
Í
Ì
30
30
30
30
Ù
Ú
80
$
?
Î
Í
Ì
30
deHaro Empty Kaiser Bld
Ù
Ú
80
Southeast
$
Empty Hospital ?
$ Bluitt-Flowers
?
Oak West $ ?
Empty Kaiser Bld Í

Î
Ì
20
Ì
Î
Í
20 Ù
Ú
175
Ì
Î
Í
35E
Ì
Î
Í
45
Ù
Ú
67

Appendix K – 3:
Community Clinic Profiles
BLUITT FLOWERS
EAST DALLAS
dEHARO-SALDIVAR
GREATER VICKERY
GARLAND
OAK WEST
SOUTHEAST DALLAS

BLUITT FLOWERS
FY 2003 Total visits = 46,048 Visits per provider FY 2003 = 3,837

Visits per exam room 1,180 1.33 Nurses/MAs per provider
2.17 clerical staff per provider
Bluitt Flowers is located in South Oak Cliff, a community that is 62% African American and 27%
Hispanic and the patients reflect the same racial mix. South Oak Cliff is one of three corridors that
have "extra low" numbers of primary care physicians contracted to see Medicaid patients. South
Oak Cliff also has some of the worst health status indicators in Dallas County.
On a monthly basis Bluitt Flowers has the capacity to see 1,904 adult and geriatric patients and
1,545 pediatric and adolescent patients. Bluitt has exceeded its adult capacity for the past several
months, particularly with geriatric patients. However, there isn't a plan to increase adult capacity
despite long waiting times to get an appointment.
Meanwhile, there have been 387 unused pediatric/adolescent appointments. This is particularly
troubling because Bluitt is located in a zip code that generates a lot of visits to Children's ED. There
is no WISH clinic located onsite. Recently, two pediatric modules were moved elsewhere in an
attempt to match resources with demand. Bluitt should work more closely with Children's ED to
ease access to follow-up appointments at its site.
Bluitt is located near the empty Kaiser facility and could benefit tremendously if specialty and
diagnostic services were offered there. Bluitt reports a backlog to obtain access to Parkland for
cardiology, GI and pain clinic. Bluitt also says it receives referrals from Parkland ED and ACC,
which other COPC sites felt was problematic. Bluitt is located in a zip code which is a top utilizer
of Parkland's ED.
The sexually transmitted disease rate in the South Oak Cliff is higher than any other part of Dallas
County. The Chlamydia rate is 1,056 per 100,000 persons compared to a Dallas rate of 449.6
(Texas 327.9). Additionally, Gonorrhea is 871 per 100,000 compared to Dallas rate of 271 and
Syphillis is 90 per 100,000 compared to Dallas rate of 29. Screenings for STDs start immediately in
all COPC clinics that serve this geographic area. We noted the teen birth rate is twice Dallas
County, 10% of all births are low birth weight and 14.6% of births occur without or unknown
prenatal care yet the WISH clinic moved out of Bluitt some time ago.
The Age adjusted death rates per 100,000 for South Oak Cliff exceed Dallas County for many
indicators: Stroke (88 S Oak Cliff /57 Dallas County), Flu (25/19), homicides (33/12), Heart
(330/231), Cancer (246/177), Diabetes (30/20), Kidney disease (23/11). When Ambulatory
Sensitive and Preventable Conditions are analyzed, the following conditions are notable:
Congestive heart failure (980 S Oak Cliff /620 Dallas County), second drug abuse (940/445),
second alcohol abuse (920/569), Diabetes (400/255), Asthma (340/218), pneumonia (335/281).
These indicators identify a community with high levels of chronic illness in need of an ambulatory
chronic disease management approach.

Bluitt Flowers
Address 303 N. Overton Rd. Dallas, 75216
Phone (214) 266-4200
Service Area S Oak Cliff
Site Administrator Kerrie Watterson
Lead Physician Donna Persaud - Peds
FY03 Clinician Visits 46,048
Clinic Services, Other Providers, Clinic Hours

Modules: Adolescent, Adult, Pediatrics, Geriatrics
Other: MHFP, Lab, Radiology, Pharmacy, Dental, Epilepsy, HIV, Mammography, Nutrition,
Optometry, Podiatry, Psychology/Psychiatry,Social Work
Nearby Y&F sites: Red Bird (3 miles west), N. Oak Cliff (3 miles northwest), South (6 miles northeast)
Spec. Referrals to: Parkland, Children's, WISH, some Methodist & Baylor
Colocated with: None
Hours: M-Th 7:30 am - 6:00 pm, Fri 8:00 am - 5:00 pm
2001 Hospital Market Share by Product Line - Service Area

Parkland Methodist Charlton Children's Baylor St. Paul Other
Obstetrics/Delivery 44.2% 18.2% 13.6% 0.0% 5.1% 6.8% 12.0%
Neonatology 42.4% 13.8% 13.1% 10.8% 4.2% 5.7% 10.1%
General Medicine 12.6% 28.3% 10.3% 12.8% 5.9% 5.2% 24.8%
General Surgery 22.9% 21.4% 10.7% 11.9% 7.7% 5.2% 20.1%
Total 22.1% 20.4% 13.3% 8.8% 8.2% 5.9% 21.4%
Demographics Poverty and Payer Source

Clinic S Oak Cliff Clinic S Oak Cliff
CY'03 undup pts 02 Pop. 00 Pop.
Af Am 13,403 66% 114,267 62% Under 100% FPL n/a n/a 38,774 21%
Hispanic 5,602 28% 49,259 27% 100-149% FPL n/a n/a 25,366 14%
White 946 5% 17,030 9% 150-199% FPL n/a n/a 22,830 13%
Other 243 1% 2,564 1% 200%+ FPL n/a n/a 94,217 52%
Total 20,194 183,120 181,187
Clinic Clinic S Oak Cliff Clinic Clinic
CY'03 undup pts 62% female 02 Pop. CY03 Enctrs PHHS Community Health
> age 5 5,429 27% 49% 14,495 8% Self-Pay 18,439 39% Plan Members Aug 2003
Age 5-14 3,228 16% 49% 31,188 17% Medicaid 17,040 36%
Age 15-44 4,065 20% 68% 79,387 43% Medicare 9,649 21% Health First 4,858
Age 45-64 5,256 26% 72% 39,641 22% Other 1,839 4% Kids First 671
Age 65 + 2,208 11% 75% 18,409 10%
Total 20,186 183,120 Total 46,967 Total 5,529
2001 Prevalence of Chronic Conditions Survey Clinic - Top Diagnoses

Source: National Research Corp. Market Guide, copyright 2001 With CY2003 number and percentage of encounters
S Oak Cliff Dallas Co. U.S. ROUTIN CHILD HEALTH EXAM 8,337 17.8%
n=106 n=1,165 n=148,758 HYPERTENSION NOS 6,655 14.2%
High Cholesterol 16.8% 25.3% 26.5% DMII WO CMP NT ST UNCNTR 2,883 6.1%
High Blood Pressure 42.5% 28.6% 32.3% BENIGN HYPERTENSION 1,217 2.6%
Asthma 28.6% 15.5% 16.0% DMII WO CMP UNCNTRLD 920 2.0%
Diabetes 15.9% 11.1% 13.5% ACUTE URI NOS 899 1.9%
Stroke 3.7% 2.6% 2.8% SCREEN MAMMOGRAM NEC 866 1.8%
OTITIS MEDIA NOS 682 1.5%
Clinic Staffing ASTHMA W/O STATUS ASTHM 672 1.4%
Providers 12.0 (2.5 Ped, 4 Internist, ROUTINE MEDICAL EXAM 670 1.4%
Nurses/MAs 17.0 .7 podiatrist, 2 lead, HYPERMATURE CATARACT 608 1.3%
Business/clerical 26.0 2.8 physician assts) DERMATOPHYTOSIS OF NAIL 596 1.3%
Other 36.7 Influenza 544 1.2%
Square footage 49,381 VIRAL INFECTION NOS 535 1.1%
Exam rooms 39.0 GYNECOLOGIC EXAMINATION 475 1.0%
ASYMP HIV INFECTN STATUS 468 1.0%
VAC-DIS COMBINATIONS NOS 457 1.0%
ALLERGIC RHINITIS NOS 433 0.9%
Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
S Oak Cliff Dallas Co. S Oak Cliff Dallas Co.
CONGESTIVE HEART FAILURE 948.2 620.1 DEHYDRATION, VOLUME DEPLETION 192.7 176.6
SECONDARY DRUG DEPENDENCY AND ABUSE 909.1 445.4 HYPERTENSION 183.4 89.3
SECONDARY ALCOHOL DEPENDENCY AND ABUSE 859.3 569.8 ALCOHOL DEPENDENCY AND ABUSE 169.9 146.8
DIABETES 357.6 255.1 DRUG DEPENDENCY AND ABUSE 96.7 96.5
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 350.2 429.1 CONVULSIONS 95.7 63.5
BACTERIAL PNEUMONIA 338.6 281.6 NUTRITIONAL DEFICIENCIES 55.8 3.0
ASTHMA 334.2 218.4 Grand Mal Status and Other Epileptic Convulsions 55.2 36.8
KIDNEY AND URINARY TRACT INFECTIONS 281.1 259.9 PELVIC INFLAMMATORY DISEASE 50.8 22.5
INJURIES 278.4 233.7 ANGINA 44.4 62.0
CELLULITIS 244.0 231.2 GASTROENTERITIS 33.6 45.9
2001 Reported Incidence of Infectious Conditions & Injuries

per 100,000 S Oak Cliff Dallas Co. U.S.
Chlamydia 1056.2 449.6 278.3
Gonorrhea 871.6 271.4 128.5
Syphillis 90.1 29.1 11.5
Esherichia coli 1.1 0.6
Samonellosis 8.2 6.0 14.4
Shigellosis 10.9 8.4 7.2
Hepatitis B carrier 18.1 13.9 12.0
Hepatitis C 211.0 114.4
Submersion injury 1.1 0.1
Streptococcal invasive disease 8.2 4.8
Meningococcal infection 4.4 1.7 0.8
Tuberculosis 45.8 11.9 5.7
Bacterial meningitis 4.4 4.2
(Conditions listed are those with higher rates than county in 2001)
Maternal and Child Health 2001 Age Adjusted Death Rates

S Oak Cliff Dallas Co. U.S. Per 100,000 S Oak Cliff Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Stroke - 2001 88.4 57.2 57.9
2001 84.7 83.9 65.3 2000 80.0 66.2 60.8
2000 82.8 80.2 65.9 1999 78.7 64.1 61.8
1999 79.0 84.5 64.4 Alzheimer's - 2001 22.3 21.2 19.1
% Births to Teens Ages Less Than 18 2000 25.4 23.7 18.0
2001 9.5% 5.3% 3.8 1999 16.4 19.3 16.5
2000 9.7% 5.8% 4.1 Flu - 2001 25.3 19.1 22.0
1999 9.3% 5.7% 4.4 2000 19.4 23.1 23.7
% of Births That Are Low Birth Weight 1999 19.2 17.1 23.6
2001 10.0% 7.7% 7.7 Accidents - 2001 18.3 16.2 35.7
2000 10.0% 7.8% 7.6 2000 16.1 14.9 35.5
1999 10.6% 7.8% 7.6 1999 18.7 15.2 35.9
Infant Mortality - Infant Deaths per 1,000 Live Births Suicides - 2001 10.5 10.3 10.7
2001 7.8 6.3 6.8 2000 5.0 8.4 10.6
2000 6.6 5.5 6.9 1999 8.0 10.7 10.7
1999 8.8 6.4 7.0 Homicides - 2001 33.8 12.9 7.1
% Of All Births (?) With No & Unknown Prenatal Care 2000 14.5 10.6 6.1
2001 14.6% 10.2% 3.7 1999 26.0 9.8 6.2
2000 12.2% 8.2% 3.9 Heart - 2001 330.7 231.7 247.8
1990 16.0% 11.4% 3.8 2000 339.0 275.7 257.9
1999 334.7 269.3 267.8
Cancer - 2001 246.2 177.4 196.0
2001 Age Adjusted Death Rates 2000 246.0 202.7 201.0
Per 100,000 S Oak Cliff Dallas Co. U.S. 1999 240.4 194.5 202.7
Diabetes - 2001 30.2 20.0 25.3 Kidney Disease - 2001 23.7 11.6 14.0
2000 37.9 26.5 25.2 2000 26.0 11.9 13.5
1999 39.7 23.5 25.2 1999 17.7 9.2 13.1
Respiratory - 2001 50.3 39.2 43.7 HIV/AIDS - 2001 20.5 7.8 5.0
2000 34.0 42.9 44.3 2000 23.9 8.1 5.3
1999 35.0 46.0 45.8 1999 25.4 9.0 5.3
Cirrhosis - 2001 16.9 8.5 9.5 Septicemia - 2001 15.6 10.0 11.4
2000 8.6 9.2 9.6 2000 12.0 12.5 11.4
1999 8.5 8.7 9.7 1999 15.3 11.5 11.3
(Causes listed are those with higher rates than county for one, more years.)
Bluitt-Flowers Health Center
$ $
$ $
$
$
$
C
$
$ $ $
$ $
$
$ C $
$ $ $
$
$ $ $ $
$
$ $
$
$ C $
$
$ $
$ $
$$ C
$ $
$ $
$ $ $ $$ $ $
$ $ C
$ $ $$
$
$
$
$
$ $
$
$ $ $
$ $ $ $$$$ $ $
$
$ $$$$$ $$ $$$ $$
$
$ $ $ $
$ $$ $ $$ $ $ $$ $ $ $
$ $ $
$$$ $$$ $$ $$ $
$ $$$$$ $ $$ $$$ $ $ $$$$$$$$ $ $
$ $$
$
$ $$
$$ $ $$ $
$$
$
$ $$ $ $$ $$
$
$$ $ $
$$$$ $$ $$$$
$ $$
$
$$
$
$ $
$$$ $
$$ $$
$
$
$
C $
$ $$ $$ $ $$ $$$
$ $ $ $$$$$ $$
$ $$ $$ $ $$$$$$$ $
$
$ $ $ $$
$$
$ $
$ $$$$$
$$
C $
Bluitt-Flowers
$ $$ $ $ $
$ $ $ $$ $
$ $ $
$ $
$$$
C
$$$$ $$$$ $$ $ $$ $
$
$$
$
$$$
$$ $ $
$
$ $
$$
$ $$
$
$ $ $ $ $ $ $ $ $$ $ $ $
$ $ $$ $$$ $$$$ $
$ $ $ $
$
$ $$ $ $ $$$$ $
$ $ $ $ $ $$$
$ $ $ $ $
$$$ $
$ $
$$ $ $$ $ $$ $ $
$ $
$ $
$ $ $ $
$$ $ $ $ $
$
$$ $$ $ $
$ $
$ $
$ $ $$ $ $
$ $ $
$ $
$ $
Bluitt Encounters by Zip Code
$ $$ $ Water Area
$ County Line
$ $ $
$ $ Zip Code Boundary
$ $
$
$
$
C COPC Clinic
$ $ $ Dot-Density
$
$ = 100 Bluitt Encounters
dEHARO-SALDIVAR

Seventy six percent (76%) of deHaro's patients are Hispanic and patients travel long distances to
access services - 13,679 patients (27% of all patients)) travel from Irving and Grand Prairie and
4,637 patients live in South Oak Cliff. deHaro is across the street from West Dallas which has very
few primary care physicians, similar to South Oak Cliff. This is a large clinic with 35 exam rooms,
and it is open on Saturdays from 8am-6pm.
Despite de-Haro's apparent efficiency, reflected in the numbers above, it has experienced a
significant pediatric decline. The monthly capacity for pediatric appointments is 2,717 (the most of
any COPC site) yet it has been averaging only 2,096 appointments per month or 621 unused
appointments. The Lead pediatrician wants to eliminate pediatric appointments and become strictly
a walk-in clinic with expanded hours. In fact, she is experimenting with the model herself. There
have been discussions of relocating the adolescent module to a nearby school-based site (Red Bird).
There is not a WISH site at deHaro; instead one is located very nearby, at the Lakewest location.
Meanwhile, the monthly adult capacity (1,537) has been fully utilized. Hypertension and Diabetes
II are frequent diagnoses along with asthma.
The ambulatory sensitive discharge rates in NW Oak Cliff for congestive heart failure is higher than
Dallas (680.7 vs. 620 per 100,000) as is chronic obstructive pulmonary disease, pneumonia, and
injuries, all preventable conditions. The discharge rate for secondary nutrition deficiency in NW
Oak Cliff is 1.5 times the discharges for Dallas (51 versus 36 per 100,000). The only age adjusted
death rate that is higher than Dallas County is Cirrhosis at 12.1 per 100,000 population versus 8.5
for Dallas an a US rate of 9.5. The 2001 Prevalence of Chronic Conditions Survey in NW Oak Cliff
reported 45.5% have high blood pressure and 36% high cholesterol. This profile, combined with
the high demand for adult and geriatric services, points out the need for a focused chronic disease
management program.

deHaro-Saldivar Health Center
Address 1400 N. Westmoreland Dallas, 75211
Phone (214) 266-0500
Service Area NW Oak Cliff (border with W. Dallas)
Site Administrator Jessica Hernandez
Lead Physician Emmanuel Inyang - Adult/Geri
Susan Briner - Peds,
Sheila White-Jackson - adolescents
FT04 Clinician Visits 52,051

Modules: Adult, Pediatrics, Geriatrics, Adolescents
Other: MHFP, Lab, Radiology, Pharmacy, Dental, Mammography, Nutrition,
Psychology/Psychiatry, Social Work, Adolescent Medicine
Nearby Y&F sites: West (1.5 miles NE), North Oak Cliff (2 miles SE), Red Bird (5 miles south)
Spec. Referrals to: Parkland, Children's, WISH
Colocated with: WISH, WIC
Hours: M-Th 7:30am-6:00 pm, Fri 8:00 am - 5:00 pm, Saturdays (urgent care) 8:00 am to 6:00 pm

Charlton Dallas
Parkland Methodist Methodist Children's Baylor SW St. Paul other
Obstetrics/Delivery 34.8% 19.5% 19.1% 0.0% 4.7% 4.9% 7.8% 9.2%
Neonatology 31.6% 13.1% 19.2% 12.7% 4.0% 3.4% 7.3% 8.7%
General Medicine 7.5% 33.6% 18.8% 14.0% 2.9% 5.3% 3.3% 14.7%
General Surgery 16.3% 21.3% 18.2% 15.3% 5.8% 6.8% 3.6% 12.7%
Total 17.1% 21.8% 21.6% 9.4% 5.6% 5.5% 5.2% 13.8%

Clinic NW Oak Cliff Clinic NW Oak Cliff
White 1,576 8% 76,880 28% 150-199% FPL n/a n/a 27,559 11%
Other 284 1% 7,038 3% 200%+ FPL n/a n/a 169,285 65%
Total 19,283 270,704 261,970
Clinic Clinic NW Oak Cliff Clinic Clinic
Age 5-14 3,308 17% 49% 47,340 17% Medicaid 24,721 48%
Age 45-64 3,525 18% 70% 53,316 20% Other 3,472 7% Kids First 1,037
Age 65 + 1,312 7% 66% 18,408 7%

Source: National Research Corp. Market Guide, copyright 2001 With 2003 number and percentage of encounters
NW Oak Cliff Dallas Co. U.S. ROUTIN CHILD HEALTH EXAM 9,635 18.7%
n=93 n=1,165 n=148,758 ACUTE URI NOS 3,753 7.3%
High Blood Pressure 45.5% 28.6% 32.3% DMII WO CMP NT ST UNCNTR 2,466 4.8%
High Cholesterol 36.0% 25.3% 26.5% HYPERTENSION NOS 1,983 3.8%
Diabetes 13.2% 11.1% 13.5% AC SUPP OTITIS MEDIA NOS 1,034 2.0%
Asthma 9.1% 15.5% 16.0% DMII WO CMP UNCNTRLD 1,028 2.0%
Stroke 2.4% 2.6% 2.8% ALLERGIC RHINITIS NOS 946 1.8%
ASTHMA W/O STATUS ASTHM 789 1.5%
Clinic Staffing ROUTINE MEDICAL EXAM 765 1.5%
Providers 13.1 (3.1 Ped, 4 Internist, LONG-TERM USE ANTICOAGUL 753 1.5%
Nurses/MAs 20.0 3 lead, 2 physician OTITIS MEDIA NOS 717 1.4%
Business/clerical 28.0 asst, 1 nurse pract.) CONTRACEPT SURVEILL NEC 668 1.3%
Other 59.3 DEPRESSIVE DISORDER NEC 596 1.2%
Square footage 36,297 FEVER 581 1.1%
Exam rooms 35.0 ACUTE PHARYNGITIS 551 1.1%
NEED PRPHYL VC VRL HEPAT 514 1.0%
SCREEN MAMMOGRAM NEC 507 1.0%
URIN TRACT INFECTION NOS 496 1.0%
NW Oak Cliff Dallas Co. NW Oak Cliff Dallas Co.
CONGESTIVE HEART FAILURE 680.7 620.1 CELLULITIS 211.0 231.2
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 348.9 429.1 DRUG DEPENDENCY AND ABUSE 79.2 96.5
BACTERIAL PNEUMONIA 333.9 281.6 CONVULSIONS 68.5 63.5
ASTHMA 258.3 218.4 SECONDARY NUTRITIONAL DEFICIENCIES 51.0 36.2
INJURIES 253.5 233.7 ANGINA 47.9 62.0
KIDNEY AND URINARY TRACT INFECTIONS 232.6 259.9 GRAND MALL STATUS & OTHER EPILEPTIC 37.9 36.8
DIABETES 221.8 255.1 GASTROENTERITIS 30.7 45.9
DEHYDRATION, VOLUME DEPLETION 212.0 176.6 VACCINE 28.3 20.7
2001 Reported Incidence of Infections Conditions & Injuries

per 100,000 NW Oak Cliff Dallas Co. U.S.
Pertussis 10.5 4.2
Chlamydia 376.0 449.6 278.3
Gonorrhea 16.9 271.4 128.5
Syphilis 1.5 29.1 11.5
Amebiasis 0.7 0.7
Salmonellosis 6.7 6.0 14.4
Botulism, foodborne 0.4 na
Streptococcal invasive disease 4.9 4.8 0.8
Memingococcal infection 2.9 1.7 5.7
Malaria 1.1 1.1

Dallas Co.
NW Oak Cliff U.S. Per 100,000 NW Oak Cliff Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Heart - 2001 230.7 231.7 247.8
2001 87.7 83.9 65.3 2000 288.8 275.7 257.9
2000 79.3 80.2 65.9 1999 240.0 269.3 267.8
1999 89.0 84.5 64.4 Stroke - 2001 64.6 57.2 57.9
2001 6.0% 5.3% 3.8 1999 44.9 64.1 61.8
2000 6.8% 5.8% 4.1 Respiratory - 2001 43.0 39.2 43.7
1999 7.3% 5.7% 4.4 2000 40.1 42.9 44.3
2001 7.8% 7.7% 7.7 Diabetes - 2001 26.4 20.0 25.3
2000 8.2% 7.8% 7.6 2000 27.9 26.5 25.2
1999 7.3% 7.8% 7.6 1999 24.5 23.5 25.2
Infant Mortality - Infant Deaths per 1,000 Live Births Flu - 2001 19.6 19.1 22.0
2001 7.5 6.3 6.8 2000 27.3 23.1 23.7
2000 5.0 5.5 6.9 1999 14.1 17.1 23.6
1999 6.1 6.4 7.0 Accidents - 2001 16.6 16.2 35.7
2001 11.0% 10.2% 3.7 1999 13.7 15.2 35.9
2000 8.9% 8.2% 3.9 Kidney Disease-2001 15.8 11.6 14.0
1990 11.9% 11.4% 3.8 2000 11.8 11.9 13.5
1999 8.7 9.2 13.1
Homicides - 2001 7.1 12.9 7.1
2000 10.9 10.6 6.1
1999 9.4 9.8 6.2
Cirrhosis - 2001 12.1 8.5 9.5
2000 7.8 9.2 9.6
1999 12.3 8.7 9.7
HIV/AIDS - 2001 6.1 7.8 5.0
2000 10.3 8.1 5.3
1999 7.3 9.0 5.3
Septicemia - 2001 10.9 10.0 11.4
2000 16.6 12.5 11.4
1999 15.0 11.5 11.3
deHaro-Saldivar Health Center $
$
$
$ $ $
$
$ $
$
C
$ $
$ $
$
$
$ $
$
$
$
$
C $
$
$ $ $
$ $
$ $ $ $ $$
$ $$ $
$ $ $ $
$ $ $$ $ $ $ $ $
$ $ $ $ $ $
$ $ $
$$ $
$ $$$ $
$
$
$ $
$
$$$
$ $
$
$
C $ $
$
$ $
$$$ $ $ $ $
$ $ $$$ $ $
$ $$ $$ $ $$ $$
$ $
$ $
$ $ $
$ $$ $$ $ $$$
$
$
$$$
$
$$ $ $ $
$ $ $$
$ $ $
C $
$ $
$$ $ $$ $$
$$$$ $$ $ $ $$ $ $ $$ $$$ $$
$ $$ $ $$ $$ $ $ $$
$ $$$
$
$ $ $
$$ $ $ $ $$$$ $$
$$ $$$
$ $$$
$
$ $$ $$$$ $ $
$ $$
$ C
deHaro
$
$ $
$
$$ $ $ $ $ $$$$$ $$$$ $$$$$
$
$ $ $ $ $$
$
$ $ $
$ $ $ $ $ $ $$ $$$ $ $ $$$ $$ $ $ $$
$ $ $$ $
$
$$$ $ $ $$$ $$ $ $ $
$ $$ $
$$$
$ $$ $$$ $ $$ $ $$$
$$$$$$$ $ $ $$ $$
$ $$ $$ $ $$ $$$$ $
$$ $ $ $ $$ $ $$ $ $ $
$ $ $$$$ $$$ $$ $$ $ $ $
$ $
$
$ $$ $
$ $ $ $ $ $$ $ $
$$$$$ $
$ $
$ $$ $
$ $
$
$
$
$ $
$ $
C
$$$ $ $ $ $ $
$ $ $$$ $ $
$
$
$
$
$ $
$$ $ C
$ $
C $
$
$$ $ $ $ $ $
$
$ $
$ $ $
$ $
$ $ $ $
$$$ $
$$ $
$
$ $$ $
$
$ $ $
$
$ deHaro Encounters by Zip Code
Water Area
County Line
$ Zip Code Boundary
$
$ C COPC Clinic
Dot Density
$
$ = 100 deHaro Encounters
EAST DALLAS

East Dallas is located in an office type building that requires use of a slow elevator to access clinical
and other services. Despite this, over the past few months East has improved its productivity and
had reduced underutilized capacity. As of August, there has been additional capacity for 118 adult
appointments and 43 pediatric appointments per month at East. (Total pediatric monthly capacity is
1,950 appointments; for adults 2,002.) Approximately 70% of East patients come from East,
Southeast Dallas and Vickery corridors. Over 1,000 patients come from Irving and 3,200 (6%)
come from South Oak Cliff. Parkland owns the building next door that contains an empty floor that
is available to East for non-patient activities.
East Dallas is located down the street from Baylor, which refers uninsured patients to East from its
ED. Baylor also operates a Medicaid clinic, Agape, that refers its high acuity patients to East. This
relationship could be expanded to include some needs and issues that may be mutually beneficial.
East also provides services in an assisted living facility, an adult day care provider, and operates a
grant funded refugee program.
The service area, East Dallas, is 36.5% Hispanic with an aging population, while East's patients are
69.6% Hispanic, 17.8% African American and 9% White and evenly divided between children and
adults. Self-pay and Medicaid patients both comprise 47% of the patient population.
Age Adjusted Death rates for East Dallas report that in 2001 the following causes of death were
higher than for Dallas County per 100,000 of population: Flu (22.4 East/19.1 Dallas), HIV/AIDS
(11.5 East/7.8 Dallas), and Homicides (13.7 East/12.9Dallas). Flu was the sixth highest clinical
diagnosis at East in 2003.
Ambulatory Sensitive and Preventable Condition discharge rates from East Dallas show Secondary
Alcohol Abuse at 738.7 per 100,000 compared to 569.8 for Dallas County an indicator that is often
related to high Homicide rates. Congestive heart failure was second with a rate of 712.9 per
100,000 compared to Dallas 620.1 with Secondary Drug Abuse leading as third with 516.9
discharges per 100,000 compared to Dallas 445.4. The East Dallas clinic site has a part time
psychologist and psychiatrist, and 3 full time social workers. It may be appropriate for East to
consider increasing its access to drug and alcohol abuse services as well as offering targeted
programming on site, including a brief screening tool for clinical providers to increase identification
of alcohol and drug abuse.

East Dallas Health Center
Address 3320 Live Oak Dallas, 75204
Phone (214) 266-1000
Service Area E Dallas Svc Area
Site Administrator Eric Walker
Lead Physician Noel Santini - Adult/Geri
LeAnn Kridelbaugh - Peds
FY03 Encounters 51,398

Modules: Adult, Pediatrics, Geriatrics
Other: MHFP, Lab, Radiology, Pharmacy, Dental, Mammography, Nutrition,
Psychology/Psychiatry, Refugee Program, Social Work
Nearby Y&F sites: Woodrow (2 miles northeast), West (3 miles west), South (3 miles southeast)
Spec. Referrals to: Parkland, Children's, WISH, Lancaster Comm., some Methodist & Baylor
Colocated with: WISH

Parkland Baylor Doctors' Presby Children's Other
Obstetrics/Delivery 43.4% 17.8% 3.5% 12.5% 0.0% 22.8%
Neonatology 45.7% 14.3% 1.8% 8.5% 9.3% 20.4%
General Medicine 7.5% 19.8% 15.5% 16.3% 10.6% 30.4%
General Surgery 17.2% 27.7% 15.2% 8.9% 11.0% 20.0%
Total 19.4% 23.4% 15.1% 11.2% 7.2% 23.6%

Clinic E Dallas Svc Area Clinic E Dallas Svc Area
White 1,500 9% 96,281 46% 150-199% FPL n/a n/a 20,761 10%
Other 591 4% 9,945 5% 200%+ FPL n/a n/a 126,419 62%
Total 16,561 211,606 205,559
Clinic Clinic E Dallas Svc Area Clinic Clinic
Age 5-14 2,267 14% 49% 25,163 12% Medicaid 21,777 41%
Age 65 + 1,049 6% 66% 21,106 10%

E Dallas Svc Area Dallas Co. U.S. ROUTIN CHILD HEALTH EXAM 9,949 19.0%
High Cholesterol 30.2% 25.3% 26.5% DMII WO CMP NT ST UNCNTR 3,557 6.8%
High Blood Pressure 26.3% 28.6% 32.3% ACUTE URI NOS 1,564 3.0%
Asthma 15.8% 15.5% 16.0% DIETARY SURVEIL/COUNSEL 1,223 2.3%
Diabetes 8.8% 11.1% 13.5% Influenza 984 1.9%
Stroke 0.0% 2.6% 2.8% VIRAL INFECTION NOS 942 1.8%
Clinic Staffing OTITIS MEDIA NOS 739 1.4%
Providers 14.3 (5.7 Ped, 5.6 Internist, AC SUPP OTITIS MEDIA NOS 684 1.3%
Nurses/MAs 24.0 2 lead, 1 nurse pract.) DMII WO CMP UNCNTRLD 642 1.2%
Business/clerical 30.0 ALLERGIC RHINITIS NOS 595 1.1%
Other 54.5 LONG-TERM USE ANTICOAGUL 570 1.1%
Square footage 43,154 DEPRESSIVE DISORDER NEC 538 1.0%
Exam rooms 30.0 URIN TRACT INFECTION NOS 496 0.9%
PSYCHOLOGICAL STRESS NEC 496 0.9%
HYPERLIPIDEMIA NEC/NOS 429 0.8%
FEVER 413 0.8%
E Dallas Svc Area Dallas Co. E Dallas Svc Area Dallas Co.
SECONDARY ALCOHOL DEPENDENCY AND ABUSE 738.7 569.8 CELLULITIS 228.8 231.2
CONGESTIVE HEART FAILURE 712.9 620.1 ASTHMA 170.4 218.4
SECONDARY DRUG DEPENDENCY AND ABUSE 516.9 445.4 DRUG DEPENDENCY AND ABUSE 116.1 86.5
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 440.7 429.1 HYPERTENSION 85.6 89.3
KIDNEY AND URINARY TRACT INFECTIONS 343.9 259.9 CONVULSIONS 62.4 88.5
INJURIES 302.6 233.7 GASTROENTERITIS 52.9 45.9
BACTERIAL PNEUMONIA 273.7 281.6 ANGINA 43.0 62.0
DEHYDRATION, VOLUME DEPLETION 245.8 176.6 SECONDARY NUTRITIONAL DEFICIENCIES 32.2 36.2
ALCOHOL DEPENDENCY AND ABUSE 238.3 146.8 Grand Mal Status and Other Epileptic Convulsions 25.6 36.8
DIABETES 235.1 255.1 VACCINE 24.9 20.7

per 100,000 E Dallas Svc Ar Dallas Co. U.S.
Chlamydia 431.9 449.6 278.3
Gonorrhea 264.1 271.4 128.5
Syphilis 28.9 29.1 11.5
Amebiasis 1.4 0.7
Hepatitis A 6.3 4.4 3.7
Lead exposure, adult 0.5 0.1
Legionellosis 0.5 0.1
Pertussis 4.8 4.2

E Dallas Svc Area Dallas Co. U.S. Per 100,000 E Dallas Svc Area Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Alzheimer's - 2001 12.8 21.2 19.1
2001 86.8 83.9 65.3 2000 21.1 23.7 18.0
2000 77.0 80.2 65.9 1999 16.4 19.3 16.5
1999 89.3 84.5 64.4 Flu - 2001 22.4 19.1 22.0
2001 4.7% 5.3% 3.8 1999 19.2 17.1 23.6
2000 5.5% 5.8% 4.1 HIV/AIDS - 2001 11.5 7.8 5.0
1999 5.7% 5.7% 4.4 2000 5.9 8.1 5.3
2001 7.8% 7.7% 7.7 Septicemia - 2001 9.8 10.0 11.4
2000 7.0% 7.8% 7.6 2000 12.9 12.5 11.4
1999 8.1% 7.8% 7.6 1999 8.5 11.5 11.3
Infant Mortality - Infant Deaths per 1,000 Live Births Accidents - 2001 15.2 16.2 35.7
2001 7.8 6.3 6.8 2000 13.1 14.9 35.5
2000 7.0 5.5 6.9 1999 13.0 15.2 35.9
1999 5.4 6.4 7.0 Suicides - 2001 8.4 10.3 10.7
2001 10.5% 10.2% 3.7 1999 11.5 10.7 10.7
2000 8.4% 8.2% 3.9 Homicides - 2001 13.7 12.9 7.1
1990 12.6% 11.4% 3.8 2000 12.7 10.6 6.1
1999 7.6 9.8 6.2
$ $
East Dallas Health Center $
$
$
$ $
$ $
$ $ $
$ $ $
$ $$ $ $
$ $ $ $
$$ $
$ $
$ $ $
$
$ $
$$$
$$
$$$ $$
$
$ $ $ C
$ $
$ $ $$ $ $
$
$
$$ $$$$$
$ $
$
$
$ $
$ $$
$
$$ $
$$
$C
$ $$ $$
$$$
$
$$ $
$ $$ $
$ $$$ $ $$ $
$ $ $$ $ $ $ $
$ $ $$
$ $$ $ $$ $
$ $ $ $$ $$ $ $
$ $ $ $ $$ $$ $ $$ $ $ $ $ $$$$ $
$ $ $$$$ $ $
$$ $
$ $ $$
$ $ $
$ $ $$ $ $$ $ $ $ $
$ $ $$$ $
$ $ $ $$$$ $$ $
$
$
C $$
$ $
$$$ $ $$
$$ $$ $$$$
$
$$$
$$
$$$
$
$$
$ $$ $ $
$$
$$ $
$ $
$
$ $
$
$$
$
$ $$$$$$$ $ $
$ $
$$ $ $ $ $ $ $
$ $$$
$ $$ $ $$ $$ $$ $ $
$
$
$$
$
$$ $$ $$ $$$$$$ $$$$$$$ $$ $ $$
$ $ $$ $$$
$$$
$$ $$$$
$$
$
EastC $
$ $ $$ $$ $$ $$
$$$ $$
$ $ $ $ $$ $ $
$$$ $$$$$
$ $ $$
$ $$ $ $ $ $$$ $ $ $ $
$ $ $$
$ $ $$$
C $
$
$
$ $$
$
$ $$ $ $
$$$ $$$
$ $ $
$$ $
$
$ $ $ $ $
$ $ $ $ $$ $ $ $ $ $
$ $ $$ $$ $$ $$
$ $
$ $ $$ $
$ $ $
$
$
$
$ $ $ $
C $
$
$ C $ $
C $
$
$
$ $ $
$ $ $$ $
$ $
$ $
$ East Dallas Encounters by Zip Code

$
Water Area
County Line
Zip Code Boundary
$ C COPC Clinic
Dot Density
$ = 100 East Dallas Encounters
GARLAND

The Garland COPC clinic was opened when the community of Garland mobilized and successfully
lobbied for its opening. Garland pediatric capacity is 1,248 appointments per month and over the
past few months the clinicians have exceeded the expected number of pediatric visits. A pediatric
module from Bluitt Flowers was recently relocated to Garland to fill a vacancy. Adult capacity is
1,672 appointments per month and Garland has averaged 158 unused appointments per month for
adults. Garland has only daytime appointments, Monday through Friday.
Garland is the first site within COPC to conduct newborn Shared Medical Appointments.
Although pediatrics is flattening across the COPC network, Garland is not experiencing the same
pediatric decline despite a lower fertility rate than Dallas County.
The Garland service area percentage of births with no or unknown prenatal care is about half that of
the other COPC clinic service areas (4.7% versus 14% South Oak Cliff, 11% Northwest Oak Cliff,
9% Vickery, 10.1% Southeast Dallas, 10.5% East Dallas).
Hypertension and Diabetes II are the top diagnoses at the Garland site. When the service area was
surveyed on the prevalence of chronic conditions in 2001, 31% reported to have high blood pressure
and high cholesterol, a slightly higher rate than Dallas County. An additional 15% reported having
asthma. Overall, the service area's health status is better than Dallas County when analyzing age
adjusted death rates and ambulatory sensitive conditions.

Garland Health Center
Address 802 Hopkins Garland, 75040
Phone (214) 266-0700
Service Area M/G/R Svc Area (Mesquite/Garland/Rowlett)
Site Administrator Dia Copeland
Lead Physician Mary Bergman - Peds, Tena Patterson - Family
Practice

Other: MHFP, Lab, Radiology, Pharmacy, Dental, Epilepsy, Mammography, Nutrition,
Psychology/Psychiatry, Social Work
Nearby Y&F sites: White Rock (6 miles SW)
Spec. Referrals to: Parkland, Children's, WISH
Colocated with: WISH, TDHS, WIC, Dental, Garland Health Dept.

Baylor Baylor Presby- Medical Mesquite
Parkland Garland University terian City Children's Comm. Others
Neonatology 25.0% 11.1% 9.9% 11.4% 7.2% 7.9% 5.2% 22.3%
General Surgery 8.8% 22.9% 10.1% 7.1% 9.8% 10.6% 4.3% 26.4%
Total 10.2% 23.8% 9.4% 8.6% 7.8% 6.6% 5.7% 27.9%

Clinic M/G/R Svc Area Clinic M/G/R Svc Area
White 2,516 21% 190,477 57% 150-199% FPL n/a n/a 26,741 8%
Other 1,095 9% 28,206 8% 200%+ FPL n/a n/a 249,367 77%
Total 12,168 331,841 322,180
Clinic Clinic M/G/R Svc Area Clinic Clinic
Age 5-14 1,263 10% 53% 56,248 17% Medicaid 15,123 47%
Age 45-64 2,839 23% 71% 70,984 21% Other 981 3% Kids First 739
Age 65 + 788 6% 67% 22,673 7%

M/G/R Svc Area Dallas Co. Texas U.S. ROUTIN CHILD HEALTH EXAM 8,574 26.6%
n=149 n=1,165 n=10,693 n=148,758 HYPERTENSION NOS 2,140 6.6%
High Blood Pressure 31.0% 28.6% 30.4% 32.3% DMII WO CMP NT ST UNCNTR 1,828 5.7%
High Cholesterol 31.8% 25.3% 25.8% 26.5% ACUTE URI NOS 1,069 3.3%
Diabetes 7.9% 11.1% 13.4% 13.5% DMII WO CMP UNCNTRLD 706 2.2%
Asthma 14.9% 15.5% 15.8% 16.0% LONG-TERM USE ANTICOAGUL 676 2.1%
Stroke 2.1% 2.6% 2.7% 2.8% Influenza 578 1.8%
OTITIS MEDIA NOS 489 1.5%
Clinic Staffing ROUTINE MEDICAL EXAM 449 1.4%
Providers 9.6 (2.8 Ped, 2 Internist, RECURR DEPR PSYCHOS-MOD 435 1.4%
Nurses/MAs 14.0 2.8 family practitioner DEPRESSIVE DISORDER NEC 399 1.2%
Business/clerical 18.0 2 lead) BENIGN HYPERTENSION 398 1.2%
Other 30.7 GYNECOLOGIC EXAMINATION 381 1.2%
Square footage 30,587 ALLERGIC RHINITIS NOS 360 1.1%
Exam rooms 25.0 EXT ASTHMA W/O STAT ASTH 343 1.1%
VIRAL INFECTION NOS 341 1.1%
AC SUPP OTITIS MEDIA NOS 324 1.0%
ACUTE PHARYNGITIS 319 1.0%
M/G/R Svc Area Dallas Co. M/G/R Svc Area Dallas Co.
CONGESTIVE HEART FAILURE 570.5 620.1 ASTHMA 167.8 218.4
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 426.8 429.1 ALCOHOL DEPENDENCY AND ABUSE 127.3 146.8
SECONDARY ALCOHOL DEPENDENCY AND ABUSE 357.0 569.8 DRUG DEPENDENCY AND ABUSE 123.1 96.5
KIDNEY AND URINARY TRACT INFECTIONS 278.1 259.9 ANGINA 68.3 62.0
BACTERIAL PNEUMONIA 270.3 281.6 CONVULSIONS 64.0 63.5
DEHYDRATION, VOLUME DEPLETION 225.6 176.6 Grand Mal Status and Other Epileptic Convulsions 27.7 36.8
CELLULITIS 188.2 231.2 EAR, NOSE, THROAT INFECTIONS 26.0 26.7
DIABETES 171.1 255.1 SECONARY NUTRITIONAL DEFICIENCIES 25.0 36.2

per 100,000 M/G/R Svc Area Dallas Co. U.S.
Salmonellosis 6.4 6.0 14.4

Aseptic meningitis 15.3 11.7
Chlamydia 240.0 449.6 278.3
Gonorrhea 100.3 271.4 128.5
Syphilis 5.8 29.1 11.5

Dallas Co. Dallas Co. U.S. Per 100,000 Dallas Co. Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Cancer - 2001 160.3 177.4 196.0
2001 70.0 83.9 65.3 2000 182.4 202.7 201.0
2000 68.6 80.2 65.9 1999 222.5 194.5 202.7
1999 72.0 84.5 64.4 Respiratory - 2001 37.9 39.2 43.7
2001 4.1% 5.3% 3.8 1999 61.9 46.0 45.8
2000 4.5% 5.8% 4.1 Diabetes - 2001 16.4 20.0 25.3
1999 4.7% 5.7% 4.4 2000 26.1 26.5 25.2
2001 7.2% 7.7% 7.7 Flu - 2001 17.5 19.1 22.0
2000 6.7% 7.8% 7.6 2000 25.0 23.1 23.7
1999 7.7% 7.8% 7.6 1999 26.1 17.1 23.6
Infant Mortality - Infant Deaths per 1,000 Live Births Septicemia - 2001 8.8 10.0 11.4
2001 5.8 6.3 6.8 2000 13.1 12.5 11.4
2000 4.4 5.5 6.9 1999 15.8 11.5 11.3
1999 5.2 6.4 7.0 Alzheimers - 2001 20.1 21.2 19.1
2001 4.7% 10.2% 3.7 1999 29.4 19.3 16.5
2000 5.7% 8.2% 3.9 Suicides - 2001 8.63 10.31 10.7
1990 6.2% 11.4% 3.8 2000 9.2 8.4 10.6
1999 9.45 10.7 10.7
Cirrhosis - 2001 9.0 8.5 9.5
2000 6.5 9.2 9.6
1999 5.4 8.7 9.7
$ $ $
Garland Health Center $

$ $ $ $$
$ $$
$
$
$ $$ $$ $
$ $
$ $ $ $ $
$ $ $ $ $
$ $ $ $$
$ $ $ $ $ $$ $$ $ $
$ $ $ $ $ $ $ $$$ $$ $ $ $
$
$ $ $$$ $
$$ $ $ $ $ $$ $$$$ $$ $ $ $
$$ $ $$ $
$$ $$$$ $$$$ $$ $ $$
$ $
$
$ $ $ $ $ $ $ $
$ $ $ $$$$$ $ $$ $ $ $
$
$ $
$$ $
$
$
$ $ $$ $
$ $ $ $ $$$$ $ $$
$$ C Garland
$ $ $ $$$$$
$ $
$$$$
$
$
$
$ $ $ $$ $ $ $ $
$$$$ $ $$
$ $$$$$$ $
$ $$ $ $
$$ $$ $ $
$$ $$
C$
$
$ $
$ $ $$
$ $$ $$ $ $ $ $$
$ $
$
$
$ $
$ $ $$ $ $
$ $ $$$ $ $ $
$ $ $
$$ $$ $ $ $
$ $ $ $
$ $
$
C $
$
$
$
$ $
$ $$ $ $
C $ $
$ $
C $
$
$
$
C $
C
C
$
$
Garland Encounters by Zip Code

Water Area
County Line
ZIP Code Boundary
C COPC Clinic
Dot-Density
$ = 100 Garland Encounters
OAK WEST

Visits per exam room 1,802 1.11 Nurses/MAs per provider 1.81 clerical staff per provider
Oak West is a small, cramped clinic with an overflowing waiting room that serves Northwest Oak
Cliff and South Oak Cliff in a facility owned by Southwestern UT. Oak West has exceeded its adult
and geriatric adult visit capacity by 231 patients per month, yet has capacity for 150 additional
pediatric visits per month, as defined by the Care Teams. (Pediatric monthly capacity is 1,014;
adult monthly capacity is 216.) Clinical staffing includes family practice, pediatrics, and a part-time
internist. Methodist Carlton refers newborns to Oak West and Baylor refers premature babies.
The surrounding communities (NW and South Oak Cliff) have 263,502 people currently living
below 200% federal poverty and 74,926 living below 100% federal poverty. The zip code that
generates the highest ED visits at Parkland is located in this area. The empty Kaiser building is
located in the same area and should be considered as a replacement facility for the existing Oak
West site, along with WISH, and specialty/diagnostic services. However, deliberate strategies to
attract an African American population should occur with relocation. South Oak Cliff has a
minimum number of Medicaid primary care providers under contract with the State of Texas.
Fifty six percent (56%) of the patients are Hispanic and 38% are African American, yet the South
Oak Cliff area is 62% African American and NW Oak Cliff is 28% African American. In the
current space, it may be difficult for Oak West to increase its attraction to the African American
population given space constraints and community perception. Half of Oak West’s patients come
from NW Oak Cliff and half from South Oak Cliff. Over forty percent of the clinical activity is
routine child health exam and Medicaid covers 69.3% of the patients. The reported incidence of
infectious conditions in NW Oak Cliff reveal a pertussis rate per 100,000 population that is twice
Dallas County or 10.5 versus 4.2, an indicator that childhood immunizations must be improved in
the area.
The sexually transmitted disease rate in the Oak West service area (South Oak Cliff) is higher than
any other part of Dallas County. The Chlamydia rate is 1,056 per 100,000 persons compared to a
Dallas rate of 449.6 (Texas 327.9). Additionally, Gonorrhea is 871 compared to Dallas rate of 271
and Syphillis is 90 compared to Dallas rate of 29 per 100,000. These STD rates are very high and
call for a concerted COPC effort, along with the Dallas County Health Department, to design a plan
for a community campaign and patient level education. Screenings for Chlamydia should be started
immediately in all COPC clinics that serve this geographic area. We note the teen birth rate is twice
Dallas County, 10% of all births are low birth weight and 14.6% of births occur without or no or
unknown prenatal care.
The Age adjusted death rates per 100,000 for South Oak Cliff exceed Dallas County for many
indicators: Stroke (88 S Oak Cliff /57 Dallas County), Flu (25/19), homicides (33/12), Heart
(330/231), Cancer (246/177), Diabetes (30/20), Kidney disease (23/11). When Ambulatory
Sensitive and Preventable Conditions are analyzed, the following conditions are notable:
Congestive heart failure (980 S Oak Cliff /620 Dallas County), second drug abuse (940/445),
second alcohol abuse (920/569), Diabetes (400/255), Asthma (340/218), pneumonia (335/281).
These indicators identify a community with high levels of chronic illness in need of an ambulatory
chronic disease management approach.
Oak West Health Center
Address 4444 S. Hampton Road Dallas 75232
Phone (214) 266-1450
Service Area S Oak Cliff (NW Oak Cliff border)
Site Administrator Kerrie Watterson
Lead Physician Renuka Khurana - peds

Modules: Adult, Pediatrics
Other: MHFP, Lab, Nutrition, Social Work, Child Life
Nearby Y&F sites: Red Bird (1.5 miles west), North Oak Cliff (4 miles north)
Spec. Referals to: Parkland, Children's, WISH, Bluitt (behavioral), Lancaster Comm., Methodist Charlton,Baylor
Colocated with: WISH
Hours: M-W 7:30 am - 6:00 pm, Th & Fri 8:00 am - 5:00 pm

Parkland Methodist Charlton Children's Baylor St. Paul Other
Neonatology 42.4% 13.8% 13.1% 10.8% 4.2% 5.7% 10.1%
General Surgery 22.9% 5.2% 10.7% 11.9% 7.7% 5.2% 36.3%
Total 22.1% 20.4% 13.3% 8.8% 8.2% 5.9% 21.4%

Clinic S Oak Cliff Clinic S Oak Cliff
White 255 4% 17,030 9% 150-199% FPL n/a n/a 22,830 13%
Other 60 1% 2,564 1% 200%+ FPL n/a n/a 94,217 52%
Total 5,865 183,120 181,187
Clinic Clinic S Oak Cliff Clinic Clinic
Age 5-14 918 16% 52% 31,188 17% Medicaid 10,229 69%
Age 15-44 552 9% 52% 79,387 43% Medicare 541 4% Health First 4,162
Age 45-64 528 9% 31% 39,641 22% Other 322 2% Kids First 527
Age 65 + 116 2% 31% 18,409 10%

S Oak Cliff Dallas Co. Texas U.S. ROUTIN CHILD HEALTH EXAM 6,399 43.4%
n=106 n=1,165 n=10,693 n=148,758 ACUTE URI NOS 647 4.4%
High Cholesterol 16.8% 25.3% 25.8% 26.5% HYPERTENSION NOS 629 4.3%
High Blood Pressure 42.5% 28.6% 30.4% 32.3% OTITIS MEDIA NOS 537 3.6%
Asthma 28.6% 15.5% 15.8% 16.0% FOLLOW-UP EXAM NEC 462 3.1%
Diabetes 15.9% 11.1% 13.4% 13.5% Influenza 378 2.6%
Stroke 3.7% 2.6% 2.7% 2.8% DMII WO CMP NT ST UNCNTR 361 2.4%
VIRAL INFECTION NOS 225 1.5%
Clinic Staffing NEED PRPHYL VC VRL HEPAT 202 1.4%
Providers 3.6 (.8 Ped, .6 Internist, ASTHMA W/O STATUS ASTHM 180 1.2%
Nurses/MAs 4.5 1 lead, .5 nurse DERMATITIS NOS 154 1.0%
Business/clerical 7.5 practioner, .7 FP) ALLERGIC RHINITIS NOS 116 0.8%
Other 3.4 ACUTE PHARYNGITIS 97 0.7%
Square footage 15,663 ND VAC HMOPHLUS INFLNZ B 95 0.6%
Exam rooms 8.0 VIRAL ENTERITIS NOS 82 0.6%
CONJUNCTIVITIS NOS 78 0.5%
ND VAC STRPTCS PNEUMNI B 77 0.5%
DMII WO CMP UNCNTRLD 77 0.5%
S Oak Cliff Dallas Co. S Oak Cliff Dallas Co.
DIABETES 357.6 255.1 DRUG DEPENDENCY AND ABUSE 96.7 96.5
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 350.2 429.1 CONVULSIONS 95.7 63.5
BACTERIAL PNEUMONIA 338.6 281.6 NUTRITIONAL DEFICIENCIES 55.8 3.0
KIDNEY AND URINARY TRACT INFECTIONS 281.1 259.9 PELVIC INFLAMMATORY DISEASE 50.8 22.5
INJURIES 278.4 233.7 ANGINA 44.4 62.0
CELLULITIS 244.0 231.2 GASTROENTERITIS 33.6 45.9

per 100,000 S Oak Cliff Dallas Co. U.S.
Chlamydia 1056.2 449.6 278.3
Gonorrhea 871.6 271.4 128.5
Syphillis 90.1 29.1 11.5
Esherichia coli 1.1 0.6
Samonellosis 8.2 6.0 14.4
Bacterial meningitis 4.4 4.2

Dallas Co. Dallas Co. U.S. Per 100,000 S Oak Cliff Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Stroke - 2001 88.4 57.2 57.9
2001 84.7 83.9 65.3 2000 80.0 66.2 60.8
2000 82.8 80.2 65.9 1999 78.7 64.1 61.8
1999 79.0 84.5 64.4 Alzheimer's - 2001 22.3 21.2 19.1
2001 9.5% 5.3% 3.8 1999 16.4 19.3 16.5
2000 9.7% 5.8% 4.1 Flu - 2001 25.3 19.1 22.0
1999 9.3% 5.7% 4.4 2000 19.4 23.1 23.7
2001 10.0% 7.7% 7.7 Accidents - 2001 18.3 16.2 35.7
2000 10.0% 7.8% 7.6 2000 16.1 14.9 35.5
1999 10.6% 7.8% 7.6 1999 18.7 15.2 35.9
Infant Mortality - Infant Deaths per 1,000 Live Births Suicides - 2001 10.5 10.3 10.7
2001 7.8 6.3 6.8 2000 5.0 8.4 10.6
2000 6.6 5.5 6.9 1999 8.0 10.7 10.7
1999 8.8 6.4 7.0 Homicides - 2001 33.8 12.9 7.1
2001 14.6% 10.2% 3.7 1999 26.0 9.8 6.2
2000 12.2% 8.2% 3.9 Heart - 2001 330.7 231.7 247.8
1990 16.0% 11.4% 3.8 2000 339.0 275.7 257.9
1999 334.7 269.3 267.8
Cancer - 2001 246.2 177.4 196.0
2001 Age Adjusted Death Rates 2000 246.0 202.7 201.0
Per 100,000 S Oak Cliff Dallas Co. U.S. 1999 240.4 194.5 202.7
Respiratory - 2001 50.3 39.2 43.7 Diabetes - 2001 30.2 20.0 25.3
2000 34.0 42.9 44.3 2000 37.9 26.5 25.2
1999 35.0 46.0 45.8 1999 39.7 23.5 25.2
Cirrhosis - 2001 16.9 8.5 9.5 Kidney Disease - 2001 23.7 11.6 14.0
2000 8.6 9.2 9.6 2000 26.0 11.9 13.5
1999 8.5 8.7 9.7 1999 17.7 9.2 13.1
Septicemia - 2001 15.6 10.0 11.4 HIV/AIDS - 2001 20.5 7.8 5.0
2000 12.0 12.5 11.4 2000 23.9 8.1 5.3
1999 15.3 11.5 11.3 1999 25.4 9.0 5.3
Oak West Health Center
C
$
$ C
$
$
$
C
$ $ $$
$$
$ C$
$
$
$ $ $ $ $ $
$
$
$ $
$ $ $ $$ $ $
$ $ $
$ $ $
$ $$$$ $ $ $$ $
$
$
$$
$ $
$
$
$
$$
$ $
$
C
$ $ $ $ $
$
$ $ $$ $ $
$ $ $ $$
$$
C$
$ $
C $
Oak
$$ $West $
$
$ $ $ $ $ $ $
$ $
$ $
$ $ $
$ $$ $$
$$$ $ $ $
$$
$$ $$ $ $
$
$ $
$ $
$
$ Oak West Encounters by Zip Code
Water Area
County Line
$ ZIP Code Boundary
$
$ C COPC Clinic
$ $ Dot-Density
$
$ = 100 Oak West Encounters
SOUTHEAST DALLAS

Southeast COPC is housed in a facility that was previously utilized as a hospital (Southeast
Methodist Hospital) and was sold to Parkland for $1. There are two empty hospital floors in
addition to empty space on the first floor. There are plans for WISH to occupy the first floor space.
Unlike the other larger community based COPC clinics, Southeast clinical space is laid out like
individual practitioner offices, which limits staffing flexibility (for example, sharing a RN or front
desk staff when each individual provider has his/her own office suite).
The most recent report on COPC productivity progress documents a serious problem at Southeast.
Available capacity at Southeast for adult and geriatrics is averaging 240 additional appointment
slots per month (total capacity is 2,364) and for pediatrics, 259 available appointment slots
(monthly capacity 1,572). The underlying issues affecting this available capacity should be
identified and addressed prior to any serious consideration of opening the Kaiser building in
Southeast Dallas. When WISH relocates its services, the pediatric demand may increase, however,
the available adult capacity is a concern because available appointments extend a month or longer.
There have been prior discussions of leasing space to social service agencies to generate more
activity in the building, as well as reconfiguring the clinical space to allow for more flexible
staffing. According to the state Medicaid agency, the number of primary care providers serving the
Medicaid population in Southeast is low.
Southeast has one of the most active Community Boards. They have conducted voter registration
drives, distributed school supplies, and advocated for running water in Sand Branch, a poor
community that relied on well water.
Thirty five percent (35%) of Southeast’s patients are on Medicaid, 44% are self-pay and 19%
Medicare, the largest elderly population in COPC clinics. Patients living in Southeast Dallas
generated twenty two percent (22%) of all pharmacy activity within COPC. This is one measure of
chronic illness. The HIV rate in Southeast Dallas far exceeds the rate in Dallas County and is
reported to be 126.2 per 100,000 population versus 45.5 (Dallas County). The Hepatitis C rate is
higher than Dallas, as well.
The top diagnoses at Southeast are hypertension and diabetes. Congestive heart failure leads the list
of Ambulatory Sensitive Conditions in this service area and is greater than Dallas County, followed
by pulmonary disease (discharges also greater than Dallas County) and alcohol and drug abuse.
Age adjusted death rates show heart rates higher than Dallas County and the US. Similarly,
Alzheimer's, homicides, and septicemia rates as causes of death were higher than Dallas and the US.
Specialty referrals in highest demand for adults are dermatology, pain clinic, CT, podiatry and
dental. For children, the highest referrals are neurology and GI. Both Mesquite Community
Hospital and Medical Center of Mesquite refer uninsured patients from their EDs.

Southeast Dallas Health Center
Address 9202 Elam Rd. Dallas, 75217
Phone 214-266-1600
Service Area Dallas SE Svc Area
Site Administrator Argentry Fields
Lead Physician Deaina Berry - peds

Other: Lab, Radiology, Pharmacy, Epilepsy, HIV, Mammography, Nutrition,
Psychology/Psychiatry, Social Work
Nearby Y&F sites: Spruce (<1 mile south), Seagoville (6 miles southeast), South (6.5 miles northwest)
Spec. Referrals to: Parkland, Children's, WISH, some Mesquite Comm., Med Ctr of Mesquite, Baylor, Doctors,
Presbyterian
Colocated with: TDHS, WIC
Hours M-F 7:30 am - 6:00 pm

Parkland Baylor Mesq. Comm Children's Doctors Presby Other
Neonatology 40.6% 14.4% 9.9% 10.0% 1.1% 4.5% 19.5%
General Surgery 19.1% 18.6% 11.1% 16.3% 6.9% 3.7% 24.3%
Total 21.1% 18.0% 13.9% 10.4% 6.9% 5.0% 24.7%

Clinic Dallas SE Svc Area Clinic Dallas SE Svc Area
White 3,278 21% 93,875 37% 150-199% FPL n/a n/a 30,190 12%
Other 311 2% 8,140 3% 200%+ FPL n/a n/a 147,270 60%
Total 15,661 254,402 245,449
Clinic Clinic Dallas SE Svc Area Clinic Clinic
Age 5-14 1,455 9% 49% 48,546 19% Medicaid 15,745 35%
Age 65 + 1,537 10% 70% 17,188 7%

Dallas SE Svc Area Dallas Co. U.S. ROUTIN CHILD HEALTH EXAM 5,813 12.9%
High Cholesterol 21.8% 25.3% 26.5% DMII WO CMP UNCNTRLD 2,382 5.3%
High Blood Pressure 39.8% 28.6% 32.3% DMII WO CMP NT ST UNCNTR 2,318 5.2%
Asthma 19.1% 15.5% 16.0% SCREEN MAMMOGRAM NEC 1,640 3.7%
Diabetes 20.6% 11.1% 13.5% ACUTE URI NOS 1,549 3.4%
Stroke 3.7% 2.6% 2.8% BENIGN HYPERTENSION 1,340 3.0%
ROUTINE MEDICAL EXAM 1,321 2.9%
Clinic Staffing OTITIS MEDIA NOS 1,269 2.8%
Providers 12.8 (2 Ped, 3.8 Internist, LONG-TERM USE ANTICOAGUL 1,230 2.7%
Nurses/MAs 16.8 2.8 FP, 2 lead DEPRESSIVE DISORDER NEC 678 1.5%
Business/clerical 29.0 2.2 nurse pract.) ACUTE PHARYNGITIS 586 1.3%
Other 43.8 ALLERGIC RHINITIS NOS 570 1.3%
Square footage 40,035 PHARMACY 543 1.2%
Exam rooms 34.0 ASYMP HIV INFECTN STATUS 437 1.0%
LUMBAGO 434 1.0%
HIV Disease 431 1.0%
Dallas SE Svc Area Dallas Co. Dallas SE Svc Area Dallas Co.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 559.4 429.1 ALCOHOL DEPENDENCY AND ABUSE 120.4 146.8
SECONDARY ALCOHOL DEPENDENCY AND ABUSE 505.7 569.8 HYPERTENSION 102.5 89.3
BACTERIAL PNEUMONIA 276.9 281.6 GASTROENTERITIS 63.5 45.9
DIABETES 276.1 255.1 ANGINA 63.5 62.0
INJURIES 273.8 233.7 EAR, NOSE, THROAT INFECTIONS 34.7 26.7
CELLULITIS 264.3 231.2 VACCINE 28.0 20.7
per 100,000 Dallas SE Svc Area Dallas Co. U.S.
HIV 126.2 45.5
Syphilis 25.6 29.1 11.5
Campylobacteriosis 5.6 2.9
Bacterial memingitis 5.9 4.2
Pertussis 4.8 4.2
Animal bites 41.5 20.5
Aseptic meningitis 16.4 11.7
Chlamydia 401.2 449.6 278.3
Gonorrhea 247.1 271.4 128.5
Maternal and Child Health 2001 Age Adjusted Death Rates (per 100,000)
Dallas SE Svc Area Dallas Co. U.S. Dallas SE Svc Area Dallas Co. U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Heart 2001 264.5 231.7 247.8
2001 87.6 83.9 65.3 2000 356.6 275.7 257.9
2000 85.3 80.2 65.9 1999 326.6 269.3 267.8
1999 91.3 84.5 64.4 Cancer 2001 150.2 177.4 196.0
2001 6.6% 5.3% 3.8 1999 209.0 194.5 202.7
2000 7.7% 5.8% 4.1 Stroke 2001 52.3 57.2 57.9
1999 7.7% 5.7% 4.4 2000 67.6 66.2 60.8
2001 8.2% 7.7% 7.7 Respiratory - 2001 42.9 39.2 43.7
2000 7.9% 7.8% 7.6 2000 68.7 42.9 44.3
1999 7.3% 7.8% 7.6 1999 60.5 46.0 45.8
Infant Mortality - Infant Deaths per 1,000 Live Births Alzheimer's - 2001 27.2 21.2 19.1
2001 7.3 6.3 6.8 2000 24.8 23.7 18.0
2000 5.6 5.5 6.9 1999 12.5 19.3 16.5
1999 8.3 6.4 7.0 Accidents - 2001 20.0 16.2 35.7
2001 10.1% 10.2% 3.7 1999 19.0 15.2 35.9
2000 8.1% 8.2% 3.9 Flu 2001 19.8 19.1 22.0
1990 10.9% 11.4% 3.8 2000 29.2 23.1 23.7
1999 18.9 17.1 23.6
Homicides - 2001 18.5 12.9 7.1
2000 10.4 10.6 6.1
1999 13.7 9.8 6.2
Diabetes - 2001 18.1 20.0 25.3
2000 42.6 26.5 25.2
1999 28.0 23.5 25.2
Suicides - 2001 12.7 10.3 10.7
2001 Age Adjusted Death Rates (per 100,000) 2000 12.1 8.4 10.6
Dallas SE Svc Area DallasCo. U.S. 1999 11.1 10.7 10.7
Kidney Disease - 2001 9.8 11.6 14.0 Septicemia - 2001 18.5 12.9 11.4
2000 17.2 11.9 13.5 2000 10.4 10.6 11.4
1999 12.7 9.2 13.1 1999 13.7 9.8 11.3
HIV/AIDS - 2001 6.0 7.8 5.0 Cirrhosis - 2001 8.6 8.5 9.5
2000 4.6 8.1 5.3 2000 16.9 9.2 9.6
1999 9.5 9.0 5.3 1999 12.7 8.7 9.7
Southeast Dallas Health Center
$
$
$
$
C
$
$ $
$
C $$ $
$ $
$$ $
$ $ $ $
$ $$$ $$$
$$ $
$ $
C $
$
$ $
$ $
$
$ $
$
$
$ $ $
$ $ $$ $ $
$ $ $
$ $C $
$ $
$$ $
$$$ $ $
$ $$$ $$ $ $
$
$$
$ $
$ $ $$ $$ $$
$ $
$ $ $$ $$ $$$ $ $$ $ $ $ $ $$$
$$$$
$
C $
$
$
$
$ $
$ $ $$
$$ $
$
$$$$ $$$ $
$
$ $$
$$ $
$$
$ $ $ $ $
$
$ $$$ $ $ $ $
$
$$ $
$$ $ $$ $$ $$ $ $ $ $ $
$ $ $ $$$ $ $ $ $ $ $
$ $ $ $$$ $$ $$$ $$$$$ $ $$ $
$ $$$ $ $$$$$ $$ $$ $ $ $ $ $
$ $ $ $ $ $
$
$
$ $ $ $
$ $
$$
$$ $ $ $
$ $ $$$ $$ $
C $$ $ $
$$ $ $
$$ $ $
Southeast $
$ $$$$$ $ $
$ $ $ $ $ $ $
$ $
$ $ $
C $ $$ $ $
$ $$ $$$$
$$ $ $ $ $$$
$$ $ $ $ $
$
C $
$$
$
$$$ $ $
$
$$ $$ $$ $ $
$ $
$$ $ $ $
$ $$ $ $ $
$ $ $$ $$ $$$$ $$ $ $ $
$
$ $$$$ $ $ $$$ $
$ $ $ $ $$ $ $
$ $
$
$
$$$ $ $$ $
$ $
$$
$
$
$ $ $
$ $ $
$ $ $
$ $$
Southeast
$
Encounters by Zip Code
Water Area
$ County Line
$ Zip Code Boundary
$
$ $
$ C COPC Clinic
$ Dot-Density
$
$ $ = 100 Southeast Dallas Encounters
GREATER VICKERY

Vickery is one of only two COPC sites to offer weekend hours. On Sunday from 8am-6pm the
clinic offers an urgent care center. The Vickery site was established in conjunction with
Presbyterian Hospital. Presbyterian pays the monthly rent and contributes approximately $126,000
year to cover operating expenses. There is a general agreement at Presbyterian and PHHS that the
facility is inadequate and needs to be relocated. Discussions to replace this facility should occur as
soon as possible.
Staff at Vickery consists of pediatricians and a family practitioner. Based on most recent reports,
unused capacity averages 109 patient slots per month, out of a total appointment capacity of 1,010.
The waiting room is shared with WISH and is overcrowded, hot and generally unpleasant.
Approximately half of Vickery’s patients come from the Vickery corridor and 25% from the
northern corridor.
The Vickery service area has a Chlamydia rate of 625.5 per 100,000 population compared to 449.6
for Dallas County and 278.3 US. The Gonorrhea rate is higher than the Dallas rate, as well. In
addition, the tuberculosis rate is five times higher than the US rate (24.9 vs. 5.7) and higher than the
Dallas rate of 11.9 per 100,000 population. The Hepatitis B carrier rate is 17.3 per 100,000
population in Vickery, compared to 13.9 for Dallas and 12 for US. All of these reportable
conditions point to the need for a collaborative effort between COPC and the Health Department to
address the identification, treatment, and reduction of these infectious conditions.
Secondary Alcohol abuse is the leading Ambulatory Sensitive discharge in the Vickery service area
at 1033.5 discharges per 100,000 persons versus 569.8 for Dallas County. The drug dependency
discharge per 100,000 is 225.8 versus 96.5 for Dallas County. The Injuries discharge rate is 459.3
compared to Dallas’ 233.7. PHHS and COPC must find additional referral sources to address
alcohol dependency and abuse.
The age adjusted death rate for stroke in Vickery service area is 71.4 versus 57.2 per 100,000
persons for Dallas County. The hypertension ambulatory sensitive discharge rate is higher than
Dallas. Hypertension is also a top Vickery diagnosis, along with diabetes. The Alzheimer’s age
adjusted death rate is 47.3 versus Dallas 21.2 per 100,000 persons. Vickery’s clinical staffing (2
peds, 1 family practice) is not designed to address the adult needs of the Vickery service area. It
should be reconsidered to more appropriately address the health status of the population and
community, including the high rates of drug and alcohol use.

Greater Vickery H. C.
Address 8224 Park Lane Dallas 75231
Phone (214) 266-0350
Service Area Vickery Svc Area
Site Administrator Dia Copeland
Lead Physician Denise Johnson - Family Practice

Modules: Adolescent, Adult, Pediatrics
Other: MHFP, Lab, Class D Pharmacy, mammography, psychology, psychiatric, social work
Nearby Y&F sites: Woodrow (4 miles south), Kiosco (5 miles west), White Rock (6 miles southeast)
Spec. Referrals to: Parkland, Children's, WISH Vivian Field (8 miles northwest)
Colocated with: WISH, TDHS
Hours M-F 8:00 am - 5:00 pm, Sunday (urgent care) 8:00 am to 6:00 pm

Parkland Presby Med. City Baylor Children's Doctor's St. Paul Other
Neonatology 40.8% 19.9% 10.0% 5.1% 8.0% 1.3% 4.6% 10.4%
General Surgery 12.1% 27.4% 17.0% 8.7% 10.7% 4.6% 1.7% 17.9%
Total 18.7% 30.1% 13.6% 7.7% 6.6% 4.8% 2.5% 16.1%

Clinic Vickery Svc Area Clinic Vickery Svc Area
White 673 12% 53,272 36% 150-199% FPL n/a n/a 15,347 10%
Other 318 6% 11,806 8% 200%+ FPL n/a n/a 94,444 64%
Total 5,686 147,569 147,569
Clinic Clinic Vickery Svc Area Clinic Clinic
Age 5-14 551 10% 46% 18,299 12% Medicaid 5,706 52%
Age 15-44 1,185 21% 69% 81,163 55% Medicare 377 3% Health First 3,217
Age 45-64 1,051 18% 73% 24,792 17% Other 354 3% Kids First 321
Age 65 + 215 4% 69% 10,182 7%

Vickery Svc Area Dallas Co. U.S. Routine child health exam 3606 32.7%
n=66 n=1,165 n=148,758 Acute urinary tract infection 410 3.7%
High Cholesterol 32.6% 25.3% 26.5% Hypertension 394 3.6%
High Blood Pressure 27.1% 28.6% 32.3% Diabetes mellitus not uncontrolled 381 3.5%
Asthma 16.0% 15.5% 16.0% Routine medical exam 337 3.1%
Diabetes 15.9% 11.1% 13.5% Ottitis media 220 2.0%
Stroke 0.0% 2.6% 2.8% Benign hypertension 208 1.9%
Fever 199 1.8%
Clinic Staffing Follow-up exam 191 1.7%
Providers 3.0 (2 Ped, 1 Lead - Family Allergic rhinitis 142 1.3%
Nurses/MAs 4.0 Practice) Diabetes mellitus uncontrolled 133 1.2%
Business/clerical 7.0 Cough 128 1.2%
Other 7.4 Recurring depression psychosis 125 1.1%
Square footage 3,809 Asthma without status asthmatic 124 1.1%
Exam rooms 9.0 Acute bronchitis 113 1.0%
Gyne exam 112 1.0%
Acute pharyngitis 107 1.0%
Urinary tract infection 103 0.9%
Vickery Svc Area Dallas Co. Vickery Svc Area Dallas Co.
SECONDARY ALCOHOL DEPENDENCY AND ABUSE 1033.5 569.8 CELLULITIS 340.0 231.2
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 397.3 429.1 HYPERTENSION 183.9 89.3
BACTERIAL PNEUMONIA 265.6 281.6 ANGINA 68.2 62
ASTHMA 222.3 218.4 SECONDARY NUTRITIONAL DEFICIENCIES 63.8 36.2
DIABETES 377.6 255.1 PELVIC INFLAMMATORY DISEASE 52.5 22.5
ALCOHOL DEPENDENCY AND ABUSE 358.3 146.8 Grand mal Status and Other Epileptic Convulsions 48.2 36.8

Vickery Svc Area Dallas Co. U.S.
Chlamydia per 100,000 625.5 449.6 278.3
Gonorrhea per 100,000 328.6 271.4 128.5
Syphilis 17.9 29.1 11.5
Tuberculosis per 100,000 24.9 11.9 5.7
Campylobacteriosis 2.8 2.9
Escherichia coli 0.7 0.6
Salmonellosis per 100,000 6.9 6.0 14.4
Shigellosis, per 100,000 8.9 8.4 7.2
Hepatitis A per 100,000 6.2 4.4 3.7
Hepatitis B carrier, per 100,000 17.3 13.9 12.0
Legionellosis 0.7 0.1
(Conditions listed are those with higher rates than county for 2001.)

Vickery Svc Area Dallas Co. U.S. Vickery Svc Area Dallas Co. Texas U.S.
Fertility Rate - Births per 1,000 Females Age 15-44 Stroke - 2001 71.4 57.2 64.5 57.9
2001 84.7 83.9 65.3 2000 61.6 66.2 66.6 60.8
2000 80.3 80.2 65.9 1999 59.1 64.1 66.3 61.8
1999 85.8 84.5 64.4 Alzheimer's - 2001 47.3 21.2 21.6 19.1
% Births to Teens Ages Less Than 18 2000 30.0 23.7 20.4 18.0
2001 4.0% 5.3% 3.8 1999 39.9 19.3 18.5 16.5
2000 3.7% 5.8% 4.1 Flu - 2001 16.9 19.1 21.9 22.0
1999 4.2% 5.7% 4.4 2000 20.9 23.1 23.1 23.7
% of Births That Are Low Birth Weight 1999 21.2 17.1 22.5 23.6
2001 8.1% 7.7% 7.7 Accidents - 2001 10.9 16.2 32.4 35.7
2000 8.7% 7.8% 7.6 2000 15.6 14.9 33.6 35.5
1999 7.8% 7.8% 7.6 1999 7.8 15.2 32.7 35.9
Infant Mortality - Infant Deaths per 1,000 Live Births Suicides - 2001 7.8 10.3 11.8 10.7
2001 5.9 6.3 6.8 2000 8.4 8.4 11.7 10.6
2000 4.6 5.5 6.9 1999 12.4 10.7 12.4 10.7
1999 7.7 6.4 7.0 Homicides - 2001 8.5 12.9 11.0 7.1
% Of All Births (?) With No & Unknown Prenatal Care 2000 14.2 10.6 11.2 6.1
2001 9.0% 10.2% 3.7 1999 4.2 9.8 10.6 6.2
2000 10.4% 8.2% 3.9 (Causes listed are those with higher rates than county for one, more years.)
1990 8.8% 11.4% 3.8
$ $
Vickery Family Health Center $

$
$
$
$
$ $
$ $ $
$$ $ $
$$ $ $
$$ $ $
$ $ $
$
$ $ $
$
$$$
$$ $
$$
$$
C
$ $
$ $ $$$
$ $ $
$$ $$$$$
$ $$$ $$
$ $ C
$ $ Vickery
$ $ $$
$
$
$$$
$
$
$
$
$
$
$
$
C $
$
$
C $
C
$
$
$
C
$
C
C
$
$
Vickery Encounters by Zip Code

Water Area
County Line
ZIP Code Boundary
C COPC Clinic
Dot-Density
$ = 100 Vickery Encounters
Appendix K - 4
COPC - Service Standards
Range of Pts. Average Pts.

Seen Per Session Seen Per Hour
Pedi - Physician 10 - 15 3.1
Pedi - Midlevel/Lead 8 - 13 2.6
Adult - Physician 8 - 12 2.5
Adult - Midlevel/Lead 6 - 10 2.0
Adol - Physician 8 - 10 2.3
Adol - Midlevel/Lead 6-8 1.8
FP - Physician 8 - 15 2.9
FP - Midlevel/Lead 6 - 13 2.4
Geri - Physician 6-8 1.8
Geri - Midlevel/Lead 4-6 1.3
Hrs per year % of Time

Working Hours per Year 2080 100.0%
Less Unavailable Time:
PTO 240 11.5%
CME 40 1.9%
Unavailable Time (hrs) 280 13.5%
Time Available 1800 86.5%
Non-Direct Patient Care Time Ranges for Non-direct Patient Care Activities
Minimum Hours Maximum Hours
Staff Physician (4% - 10%) 72 180
Lead Physician (10% - 20%) 180 360
Staff Physician Lead Physician

(5%) Non-direct (15%) Non-direct
Average Non-direct Time 90 270
Less:
Staff Meetings 24 24
Forums 48 48
Lead Meetings 0 48
Total Standard Non-Pt. Care Activities 72 120
Maximum amount of Negotiable Project Time 18 150
Staff Physician Lead Physician

Maximum (10%) Non-direct Maximum (20%) Non-direct
Maximum Non-direct Time 180 360
Less:
Staff Meetings 24 24
Forums 48 48
Lead Meetings 0 48
Total Standard Non-Pt. Care Activities 72 120
Maximum amount of Negotiable Project Time 108 240
NOTE:
The usage of maximum non-direct patient care is reserved only for those high performers who
consistently exceed service targets. Using the maximum non-direct patient care will require VP and
Medical Director approval; specific projects/initiatives must be outlined for review.
Table 4.4a: Per FTE Physician – Staffing, RVUs, Patients, Procedures and Square Footage With Primary Care Only
Staffing, RVUs Practice Type
Patients, Procedures and Multispecialty Primary Care Only (per FTE Physician)
Square Footage Data Count Mean Std. Dev. 10th %tile 25th %tile Median 75th %tile 90th %tile
Total provider FTE/physician 27 1.37 0.24 1.09 1.15 1.32 1.5 1.73
Prim care phy/physician 35 0.97 0.09 0.83 1 1 1 1
Non spec phy/physician 6* * * * * * *
Surg spec phy/physician 1* * * * * * *
Total NPP FTE/physician 27 0.37 0.24 0.09 0.15 0.32 0.5 0.73
Total support staff FTE/phy 36 5.29 1.78 3.13 4.28 5.16 5.8 8.07
Total empl support staff FTE/phy 35 5.06 1.52 3.05 4.25 5.05 5.74 7.34
General administrative 32 0.4 0.26 0.1 0.19 0.32 0.67 0.83
Business office 32 0.75 0.38 0.41 0.5 0.69 0.91 1.12
Managed care administrative 11 0.25 0.19 0.02 0.12 0.18 0.41 0.54
Information technology 11 0.11 0.15 0.03 0.04 0.05 0.11 0.47
Housekeeping,maint,security 20 0.15 0.16 0.01 0.04 0.1 0.23 0.42
Medical receptionists 31 1.07 0.47 0.45 0.71 0.98 1.48 1.7
Med secretaries,transcribers 17 0.26 0.18 0.02 0.12 0.21 0.36 0.56
Medical records 22 0.43 0.22 0.17 0.25 0.43 0.55 0.78
Other admin support 14 0.27 0.24 0.04 0.1 0.17 0.45 0.71
Registered Nurses 27 0.47 0.39 0.16 0.18 0.36 0.54 1.09
Licensed Practical Nurses 24 0.69 0.53 0.13 0.23 0.5 1.18 1.36
Med assistants, nurse aides 30 0.87 0.43 0.26 0.52 0.82 1.19 1.36
Clinical laboratory 23 0.36 0.26 0.11 0.17 0.27 0.51 0.75
Radiology and imaging 17 0.25 0.18 0.09 0.14 0.18 0.32 0.57
Other medical support serv 11 0.29 0.21 0.04 0.13 0.2 0.42 0.68
Total contracted sup staff 13 0.25 0.32 0.04 0.08 0.16 0.28 0.9
Total RVU/physician 7* * * * * * *
Physician work RVU/physician 4* * * * * * *
Patients/physician 22 2,582 1,623 1,286 1,387 2,083 3,358 6,088
Total procedures/physician 28 11,349 4,281 5,227 7,929 10,924 14,247 17,882
Square feet/physician 31 2,256 1,195 1,081 1,341 1,965 2,942 4,162
Copyright 2002. All Rights Reserved. Medical Group Management Association

COPC Staffing Tool
June 25, 2004 Appendix A - 5
East Dallas Senior

Health Bluitt Youth and House
Center DeHaro Flowers Southeast Garland Oak West PPCC Vickery Family ACC Geriatrics Calls HOMES
DECISION CRITERIA
Provider/Staffing Ratio (budgeted staff)

Providers 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Nurses and MAs 1.68 1.53 1.42 1.31 1.46 1.25 1.67 1.33 1.20 1.55 2.31 0.36 1.27
Business and Clerical 2.10 2.14 2.17 2.27 1.88 2.08 2.33 2.33 1.26 1.36 1.15 0.36 1.27
Provider/Staffing Ratio (current staff)

Providers 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Nurses and MAs 1.71 1.07 1.33 1.23 1.63 1.11 1.33 1.00 1.20 1.36 2.31 0.36 1.27
Business and Clerical 2.28 2.06 2.17 2.19 1.86 1.81 2.33 2.00 1.26 1.36 1.15 0.36 1.27
Exam Rooms per Provider 2.10 2.67 3.25 2.66 2.60 2.22 2.67 3.00 n/a 0.00 0.00 0.00 n/a
Staffing Models
Providers 14.3 13.1 12 12.8 9.6 3.6 3 3 12.5 11 2.6 2.8 5.5
Nurses and MAs 24 20 17 16.8 14 4.5 5 4 15 17 6 1 7
Business and Clerical 30 28 26 29 18 7.5 7 7 15.8 15 3 1 7
Vacancies
Providers 2 1 0
Nurses and MAs 3 6 1 1 0 0.5 1 1 2
Business and Clerical 2 1 1 2 1 1 0
DETAILED INFORMATION
Square Footage 51,398 52,051 46,048 44,716 31,796 14,419 9,855 10,751 27,975 47,951 947 N/A 11,344
Exam Rooms
Adult 16 12 13 17 13
Pediatrics 14 17 15 12 12 6 3
Other 6 11 5 8 2 6
Other Patient Care Rooms

Adult 3 1 1 3 2
Pediatrics 4 1 1 1 2
Other 2 1 3
Providers
Pediatricians 5.7 3.1 2.5 2 2.8 0.8 2 1 0.5
Internist 5.6 4 4 3.8 2 0.6 2 1 0.8 1
Family Practitioner 2.8 2.8 0.7 1 2 1 0.5
Podiatrists 0.7
Leads 2 3 2 2 2 1 1 1 1 1 1
Nurse Practitioners 1 1 2.2 0.5 5 1.6 2 3
Physician Assistants 2 2.8 4 7
Nursing Staff
Lead RN's 2 3 2 1 2 1 1 1 1 1 1 1
RN's 6 4 3 3.8 2 1 2 14 1 5
LVN's 8 12 9 11 9 3.5 2 2 9 2 1 1
Medical Assistants 8 1 3 1 1 2 3 2 1
Patient Care Assistants 2
Clinical Nurse Specialist 1
Business Staff
CSA's 17 13 12 22 11 4 5 5 11.8 11 2 3
Financial Counselor 7 8 9 6 3 2 1 2 4 4 1 1 4
Appointment Scheduler 6 7 5 1 4 1.5 1
Medical Office Assistant
Administrave Sec.& Assistants 2 2 2 2 1 1 1 1 1 1

Management and Supervision 1 1 1 1 1 1 1
Other 1 1 4 6.2
Language Assistants 3 3 2 3 3 1 1 1 0 0 1
Social Workers 3 3 2 2 0.5 1 0.5 3 0 1 1 3.2
Psychologist 0.45 0.7 0.45 0.6 0.85 0 0 0.2 0 0 0.2
Psychiatrist 0.2 0.4 0.4 0.4 0.4 0 0 0.2 0 0
Community Service 1 1 1 1 1
January - March 2004 APPENDIX K-6
EPIC REPORT
Newborn Appointments Parkland to COPC
Dale Talley
% % % %
Regular Appts Appts Appts High Ris Appts Appts Appts
Appts Kept Kept Kept Appts Kept Kept Kept
January 1,156 82.6% 955 82.6% 33 92.6% 31 92.6%
February 1,083 86.0% 931 86.0% 33 92.7% 31 92.7%
March 1,185 85.8% 1,017 85.8% 40 98.4% 39 98.4%
April 1,186 85.9% 1,019 85.9% 40 87.5% 35 87.5%
May 1,015 82.4% 836 82.4% 52 78.1% 41 78.1%
June 1,018 84.3% 858 84.3% 35 91.7% 32 91.7%
July 1,179 85.4% 1,007 85.4% 57 94.7% 54 94.7%
August 1,178 84.5% 995 84.5% 35 88.5% 31 88.5%
TOTAL 9,000 7,619 84.7% 325 293 90.2%

2004 Consultants' Warnings To Parkland

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

2004 Consultants' Warnings To Parkland

Diunggah oleh

Hak Cipta:

Format Tersedia

•

180 North LaSalle Street

8888 Keystone Crossing

Pat Terrell, Project Manager

Health Management Associates November 2004

Health Management Associates 1 November 2004

Long-Term Planning Issues ........................................................................................................ 70

Health Management Associates 2 November 2004

APPENDICES ................................................................................................ 112

A. Project Interview/Interaction Listing

Health Management Associates 3 November 2004

Health Management Associates 4 November 2004

• There is an unusual and exemplary level of interest in and commitment to assuring

• Dallas County is a growing and changing community. The population in Dallas

Health Management Associates 5 November 2004

• Dallas County is providing a significant contribution to health care for low-income

Health Management Associates 6 November 2004

• Specific strategic initiatives should be undertaken to assure that Parkland operates

Priorities for Parkland System Clinical Operations

2) Begin, in partnership with the University of Texas Southwestern (UTSW), a process to

Health Management Associates 7 November 2004

for expansion or contraction of clinics based on population growth or movement, and

Health Management Associates 8 November 2004

16) Establish bed control as an institutional priority, building on recommendations from

Health Management Associates 9 November 2004

renovation of existing space for the establishment of increased rehabilitation capacity

Priorities for Health Care Financing

1) Leverage available Dallas County funds through a variety of special financing

• Take advantage of additional Upper Payment Limit (UPL) payments by

• Increase Medicaid payments to Parkland and UTSW physicians.

Health Management Associates 10 November 2004

4) Convert Parkland’s COPC clinics to Federally Qualified Health Centers (FQHCs).

8) Continue to build on revenue cycle improvements by increasing conversion of patients

Health Management Associates 11 November 2004

10) Ensure that Parkland is positioned to take advantage of pharmacy opportunities

Priorities For Partnership Development and Expansion

2) Develop expanded collaboration with Children’s Medical Center, particularly focusing

Health Management Associates 12 November 2004

Priorities for an Effective Health System Governance

2) Empower the Dallas County Commissioners Court to appoint a civic “nominating

Health Management Associates 13 November 2004

CHAPTER 1: WHAT IS THE CURRENT HEALTH OF DALLAS COUNTY?

A. The Population to be Served

The Dallas County Population

Health Management Associates 14 November 2004

Health Management Associates 15 November 2004

The Parkland Patient Population

Health Management Associates 16 November 2004

Future Demographic Trends

Health Management Associates 17 November 2004

B. The Health Status of Dallas County

What is “Health Status?”

Health Management Associates 18 November 2004

Health Status of Dallas County

Health Management Associates 19 November 2004

Health Status of the Parkland Population

Health Management Associates 20 November 2004

Key Health Conditions to be Addressed

In addition to increased diabetes, the African American population suffers disproportionately

Health Management Associates 21 November 2004

Characteristics of the Dallas County Economy

L e is u r e & h s o p ita lity 9 %

Health Management Associates 22 November 2004