december 1, 2008dept of health and human services1 state of new hampshire department of health and...
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December 1, 2008 Dept of Health and Human Services 1
State of New HampshireDepartment of Health and Human Services
Public Hearing on Budget RequestMonday, December 1, 2008Commissioner Nick Toumpas
December 1, 2008 Dept of Health and Human Services 2
Presentation Objectives
Outline DHHS SFY 10/11 Maintenance and Change Budget Request
Focus centered on big picture, not program or function specifics
December 1, 2008 Dept of Health and Human Services 3
Today’s Agenda
Today’s objectives
DHHS profile, background and context External environment and assumptions DHHS Response Budget request overview Question and answer session
December 1, 2008 Dept of Health and Human Services 4
Department of Health and Human Services
ProfileBackground
Context
December 1, 2008 Dept of Health and Human Services 5
Mission Statement
“To join communities and families in providing
opportunities for citizens to achieve
health and independence”
December 1, 2008 Dept of Health and Human Services 6
Responsibilities
To meet the health needs of New Hampshire citizens
To meet the basic human needs of New Hampshire citizens
To provide treatment and support services to those who have unique needs including disabilities, mental illness, special health care needs or substance abuse problems
To protect and care for New Hampshire’s most vulnerable citizens
December 1, 2008 Dept of Health and Human Services 7
Guiding Principles
Services
Community basedFamily orientedPrevention
orientedCrisis responseOutcome based
Operations
Fiscal responsibility Workforce quality Management
quality Information rich Open
communications
December 1, 2008 Dept of Health and Human Services 8
Department Profile
3,350 Authorized positions Approximately 70% are in direct care roles Maintaining vacancy rate for budget savings
52 locations statewide Operates 7 24x7 facilities
Sits at the hub of several interdependent service delivery systems 14 client focused organizations within DHHS Work through several primary service distribution
systems Supported by several thousand other organizations,
large and small under contract or as enrolled providers
December 1, 2008 Dept of Health and Human Services 9
Disease surveillance
Disease control and prevention
Community health
Laboratory services
Prevention services
J ose T . Montero, MD
Director
Division of Public Health S ervices
Provider payments, Rx
A cute care services
S CHI P
Katie Dunn
Medicaid Director
O ffi ce of Medicaid Business & Policy
E lder ly and adult services, T obey S chool
Behavioral health, developmental services
Homeless and Housing S ervices
Drug and A lcohol S ervices
DDU medical eligibility
N ancy L. Rollins
A ssociate Commissioner
Division of Community Based Care S ervices
Children, Youth and Families
J uvenile J ustice S ervices
Family A ssistance
Child S uppor t S ervices
N ew Hampshire Hospital
Glencliff Home
Mary A nn Cooney
Deputy Commissioner
Direct Programs/ O perat ions
Budget and fi nance operat ions
Employee A ssistance Program
J ames P. Fredyma
Controller
O ffi ce of Business O perations
Licensing and cer t ifi cation
Legal services
O mbudsman
Estate Recover ies
A dministrat ive appeals
Mary P. Castelli
S r . Director
O ffi ce of O perat ions S uppor t
Q uality assurance
T hird par ty liability
S urveillance and ut ilization review
S pecial investigations
Continuous improvement
I nf ormation technology
I nternal audits
O ffi ce of I mprovement, I ntegr ity & I nf ormation
S tephen J . Mosher
Linda S . Paquette
W illiam Baggeroer
Emergency services
Human resources
Public inf ormation offi ce
A dministrat ion
Lloyd W . Peter son, A ssociate Commissioner
J ohn D. W allace, A ssociate Commissioner
A dministrat ion
N ick T oumpas
Commissioner
Organization Structure
December 1, 2008 Dept of Health and Human Services 10
The External Environment
December 1, 2008 Dept of Health and Human Services 11
Citizen Expectations
The impact of the Internet and widespread use of information and communications technologies have transformed every industry
Citizens expect more from the public sector Transparency Accessibility Efficiency Accountability Short term intervention leading to results
December 1, 2008 Dept of Health and Human Services 12
The Perfect Storm
We are in a “ permanent fiscal crisis” driven by several factors outside of our control and to which we must respond
The Federal government is downshifting financial burden to the States
The globalization of the economy is a reality The changing demographics in New Hampshire
December 1, 2008 Dept of Health and Human Services 13
DHHS Challenges
Increasing numbers and complexities of clientsCost of medical services
Growing faster than inflation or State revenuesNeed for emergency planning Purchasing methodologies based too focused on cost
Not enough on outcomes and improvementsLitigationFederal/State/County/Local relationshipsAdapting organization to address increased demands
With fewer resourcesInformation technology-working with old technology
December 1, 2008 Dept of Health and Human Services 14
Assumptions for Budget Development
Personnel All positions are fully funded Benefits calculated at estimated cost for each employee
Inflation factors to adjusted SFY09 totals · Consumer Price Index SFY10-2.3%, SFY11-2.3% · Food Price Index SFY10-5.5%, SFY11-5.0% · Utilities/Energy SFY10-20.0%, SFY11-5.0% · Travel SFY10-16.0%, SFY11-5.0% · Medical SFY10-4.1%, SFY11-4.1%
Caseload Increases Maintenance budget includes anticipated growth in caseloads in
entitlement programs. Caseload growth for non-entitlement programs budgeted in
Change
December 1, 2008 Dept of Health and Human Services 15
The DHHS Response
Segment the populations we serve by primary need
Underlying drivers in each segment require specific response
December 1, 2008 Dept of Health and Human Services 16
DHHS Client CountsAs of September, 2008
7,966
66,500
2,198
1,448
7,052
8,930
66,087
103,944
120,083
Healthy Kids Silver
Healthy Kids Gold
Adoption & Foster Care
Old Age Assistance
APTD
TANF
Food Stamp
Total Medicaid
Unduplicated Individuals
December 1, 2008 Dept of Health and Human Services 17
Need Based Segmentation
DHHS serves three interdependent sets of needs for the population Health and Medical Long-Term Care Human Services
DHHS has reached out to a set of external stakeholders to discuss the challenges, the opportunities and the strategies for the responding to challenges while looking to transform
December 1, 2008 Dept of Health and Human Services 18
Stakeholder Council for Health & Medical Services
DHHS Program Units Division of Public Health Services Office of Medicaid Business & Policy DCBCS-Bureau of Drug & Alcohol Services DCBCS-Bureau of Behavioral Health New Hampshire Hospital
Stakeholder OrganizationsAmerican Cancer Society, Bi-State Health Association, Bi-State Primary Care Association, Endowment for Health, Foundation for Healthy Community, Governor Commission on Alcohol/Drug Prevention, Healthy New Hampshire Foundation, MCAC, Medial Care Advisory Committee, NAMI NH, NH Ambulance Association, NH Ambulatory Surgery Association, NH Citizens Health Initiative, NH Community Behavioral Health Association, NH Dental Society, NH Hospital Association, NH Institute of Health Policy, NH Medical Society, NH Pediatrics Society, NH Pediatric Society, NH Public Health Association, Pierce Law Center, Rochester District VNA, Rural Home Care Network, State of NH Department of Insurance…
December 1, 2008 Dept of Health and Human Services 19
Stakeholder Council for Long-Term Care Services
DHHS Program Units DCBCS-Bureau of Elderly & Adult Services DCBCS-Bureau of Developmental Services Glencliff Home
Stakeholder OrganizationsAARP, Brain Injury Association of NH, Council on Developmental Disabilities, CSNI, Dartmouth Medical School, Disability Rights Center, ENGAGING NH, Governor’s Commission on Disability, Independent Case Management Association, Medical Care Advisory Committee, NH Adult Day Services Association, NH Association of Counties, NH Association of Senior Centers, NH CARES, NH Catholic Charities, NH Coalition of Aging Services, NH Health Care Association, NH Home Care Association, NH Seniors Count, Private Provider Network, State Council on Aging….
December 1, 2008 Dept of Health and Human Services 20
Stakeholder Council for Human Services
DHHS Program Units Division of Children, Youth, & Families Division For Juvenile Justice Services Division of Family Assistance DCBCS-Bureau of Homeless & Housing Services DCBCS-Tobey School Division of Child Support Services Office of Operations Support-Legal & Ombudsman
Stakeholder OrganizationsBonnie CLAC, Catholic Charities, Child Care Advisory Council, Community Action Association, Courts, Interagency Council on homelessness NH Alcohol & Other Drugs Services Providers Assoc, NH Coalition Against Domestic and Sexual Violence, NH Community Loan Fund, NH Council on Developmental Disabilities, NH Employment Security, NH Foster & Adoptive Parents Association, NH Healthy Kids, NH Homeless Providers Association, NH Housing, NH Legal Assistance, NH Partners in Service, Office of Energy and Planning, State Coordinating Council for Community Transportation, State of NH Corrections, State of NH Education, Workforce Opportunity Council….
December 1, 2008 Dept of Health and Human Services 21
Goal is greaterHealth & Independence
HEALTH & INDEPENDENCE
Health & Medical Services
Long Term Care
Services
Human Services
Safety Net
Improvement
December 1, 2008 Dept of Health and Human Services 22
Health and Medical
Cost drivers Cost shifting Rising cost of medical care services Greater complexity of cases Greater incidence of co-morbid conditions Impacts of mental illness
Manifested by Provider payments Outpatient Children’s mental health
December 1, 2008 Dept of Health and Human Services 23
Medicaid Medical Assistance
Medicaid Medical Assistance
0
100,000
200,000
300,000
400,000
500,000
600,000
F03 F04 F05 F06 F07 F08 F09 F10 F11
Cos
t ($0
00)
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
Clie
nts
Medical Assistance Average Monthly Caseload
December 1, 2008 Dept of Health and Human Services 24
SCHIP Enrollment and Average Cost
SCHIP
$-
$500
$1,000
$1,500
$2,000
$2,500
SFY2002
SFY2003
SFY2004
SFY2005
SFY2006
SFY2007
SFY2008
SFY2009
SFY2010
SFY2011
Co
st P
er C
hil
d P
er Y
ear
-1,0002,0003,0004,0005,0006,0007,0008,0009,000
Ave
rag
e M
on
thly
E
nro
llm
ent
Avg annual cost Avg # enrolled/month
December 1, 2008 Dept of Health and Human Services 25
Behavioral Health
Behavioral Health
$0
$500
$1,000
$1,500
$2,000
$2,500
SFY2002
SFY2003
SFY2004
SFY2005
SFY2006
SFY2007
SFY2008
SFY2009
SFY2010
SFY2011
Cos
t per
Cas
e
-
10,000
20,000
30,000
40,000
50,000
60,000
Und
uplic
ated
Cas
es
Cost per Case Unduplicated Cases
December 1, 2008 Dept of Health and Human Services 26
Public Health Primary Care
Public Health Primary Care
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
SFY2002
SFY2003
SFY2004
SFY2005
SFY2006
SFY2007
SFY2008
SFY2009
SFY2010
SFY2011
Nu
mb
er
of
Cli
en
ts
December 1, 2008 Dept of Health and Human Services 27
Health and Medical Distribution System
The primary organizations through whom DHHS works include The 26 acute care hospitals
• 13 have the critical access designation The New Hampshire Hospital The 24 Community Health Centers
• Federally qualified health centers• Look alike centers
The 10 Community Mental Health Centers These organizations are supported by a large number of
other organizations under contract to DHHS and or to the agency or as “enrolled providers”
December 1, 2008 Dept of Health and Human Services 28
Long-Term Care
Cost drivers Aging of the population Greater incidence of co-morbid conditions Greater complexity of conditions Increase in community based care need Developmental disabilities
• Alzheimer's for the elderly• Autism for youth
December 1, 2008 Dept of Health and Human Services 29
Long Term CareDevelopmental Services
December 1, 2008 Dept of Health and Human Services 30
Long Term Care ServicesMedicaid ElderlyNursing Level of Care-Costs & Clients
0
50
100
150
200
250
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Co
sts
(in
$M
illi
on
s)
Exclu
des M
QIP
-
1,000
2,000
3,000
4,000
5,000
6,000
No
. o
f C
lien
ts
Nursing Home Cost Community Based Cost
Nursing Home # Clients Community # Clients
December 1, 2008 Dept of Health and Human Services 31
Trends In Long Term Care
-1000
0
1000
2000
3000
4000
5000
6000
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Est
2010
Bud
2011
Bud
NursingFacility
HCBC/AFC
Mid-level
December 1, 2008 Dept of Health and Human Services 32
Long-Term CareDistribution System
Primary partners Nursing Homes
11 Public/County nursing homes 65 Private nursing homes Glencliff Home
4 Independent Case Management organizations 13 ServiceLink Resource Centers 10 Area Agencies These primary partners are supported by a
significant number of other individuals and contract providers.
December 1, 2008 Dept of Health and Human Services 33
Human Services
Cost drivers Deterioration in the national and State economy is
driving demand for human services Food stamps Energy assistance Healthy Kids Also increases in reported abuse and neglect to both
children and the elderly
December 1, 2008 Dept of Health and Human Services 34
Human ServicesAbuse & Neglect
Child & Family Services Services for Abused & Neglected Children
$10,500
$11,000
$11,500
$12,000
$12,500
$13,000
$13,500
2002 2003 2004 2005 2006 2007 2008
Co
st
of
Serv
ices/C
lien
t
Serv
ed
0
5,000
10,000
15,000
20,000
25,000
Call
s T
o C
en
tral
Inta
ke
Cost of Services Per Client Served Call to Central Intake
December 1, 2008 Dept of Health and Human Services 35
Human ServicesTANF
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
2005 2006 2007 2008 2009 2010 2011
In M
illio
ns
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
TANF GRANTS
# o
f C
aselo
ads
Annual Cost ($000) Caseloads
December 1, 2008 Dept of Health and Human Services 36
Human Services Distribution System
Primary organizations 12 District Offices 6 Community Action Agencies The NH Employment Program The city and town welfare agencies
Supported by a very large number of smaller organizations that are public, private and increasing number of faith-based organizations
December 1, 2008 Dept of Health and Human Services 37
DHHSAdministrative Oversight & Support
DHHS Program Units Office of the Commissioner Office of Operations Support-LICENSING, RULES, GENERAL COUNSEL Office of Improvement, Integrity and Information Program Division/Bureau administration
Medicaid Enhancement Disproportionate Share Hospital (DSH) - UNCOMPENSATED CARE Disproportionate Share (DSH) - NEW HAMPSHIRE HOSPITAL Proportionate Share (Pro Share) - NURSING COUNTY NURSING HOMES Medicaid Quality Improvement Program (MQUIP) - NURSING HOMES
December 1, 2008 Dept of Health and Human Services 38
Overview of Department’s Budget Request
Agency PhaseMaintenance and Change
SFY 10 and SFY 11
December 1, 2008 Dept of Health and Human Services 39
Budget Development Influences
Beneficiaries Aging population with too few resources for long term care Unrestricted access to medical care with no responsibility
for healthy choices and outcomes Significant increase in children diagnosed with autism Substance abuse pervades many lives and programs
Providers Rate structure is inflexible, non-uniform, and inadequate in
some areas Payment methods do not promote/reward efficiency,
innovation and outstanding performance of providers Federal Funding
Federal budget initiatives and changes in federal program management place federal funding at risk
December 1, 2008 Dept of Health and Human Services 40
Provider Rate Increases Maintenance & Change Budget
Agency budget included rate increases on July 1 each year.
46.4%
36.5%
8.3%
4.1%
4.1%
4.1%
4.1%
4.1%
6.8%
4.1%
3.0%
3.0%
3.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Medicaid Admin - Transportation
Provider Payments - Dental-Rate Increase
HB43-Change Budget
Nursing Facility
HCBC
Midlevel
Case Management
Home Health, Wheelchair Van, Adult Medical Day
Community Mental Health Centers
Developmental Services Area Agencies
DCYF Residential Providers
DCYF Ancillary Services
Child Care
December 1, 2008 Dept of Health and Human Services 41
Budget byExpense Class
I n Millions
Expense Class SFY 09 SFY 10 SFY 11
Administration
Non-personnel 42.50$ 2.19% 44.55$ 2.08% 45.76$
Personnel 228.32$ 11.79% 247.85$ 11.58% 255.97$
Consultants 2.30$ 0.12% 1.07$ 0.05% 1.11$
Operations Services 9.74$ 0.50% 1.37$ 0.06% 1.39$
Contracts
Evaluation & Mgt Services 3.67$ 0.19% 3.84$ 0.18% 4.10$
Program Services 115.73$ 5.98% 136.75$ 6.39% 125.38$
Social Services 1.43$ 0.07% 1.46$ 0.07% 1.52$
Medical Program Expense 1,310.63$ 67.68% 1,475.63$ 68.97% 1,586.86$
HS Program Expense 195.31$ 10.09% 199.01$ 9.30% 205.37$
I T Expense 26.93$ 1.39% 28.14$ 1.32% 28.69$
Total Funds Expense 1,936.56$ 100.00% 2,139.67$ 100.00% 2,256.15$
GF Expense 720.30$ 806.38$ 854.09$
December 1, 2008 Dept of Health and Human Services 42
Dept of Health and Human Services
Agency Request
SFY08 SFY09 SFY10 SFY11 SFY10 SFY11
GENERAL $670 $720 $806 $854 $95 $107FEDERAL $884 $944 $1,028 $1,078 $65 $78OTHER $285 $274 $307 $326 ($9) ($9)TOTAL $1,839 $1,939 $2,142 $2,258 $151 $176
MAINTENANCE CHANGE
December 1, 2008 Dept of Health and Human Services 43
Maintenance RequestTotal Funds SFY 10/11
$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
Health & Medical Long Term Care Social Services Administration MedicaidEnhancement
Ro
un
de
d t
o $
00
0
SFY08 SFY09 SFY10 SFY11
December 1, 2008 Dept of Health and Human Services 44
Maintenance RequestTotal Funds SFY 10/11
Total Funds
28%
14%
5%
15%
38%
Health & Medical
Medicaid Enhancement
Administration
Social Services
Long Term Care
December 1, 2008 Dept of Health and Human Services 45
Maintenance RequestGeneral Funds SFY 10/11
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
Health & Medical Long Term Care Social Services Administration
Fig
ure
s R
ou
nd
ed
to
$0
00
SFY08 SFY09 SFY10 SFY11
December 1, 2008 Dept of Health and Human Services 46
Maintenance RequestGeneral Funds SFY10/11
GENERAL FUNDS
49%
25%
19%
7%
Health & Medical
Administration
Social Services
Long Term Care
December 1, 2008 Dept of Health and Human Services 47
Change Budget RequestGeneral Funds SFY 10/11
General FundsFigures Rounded to $000
$20,554
$13,442
$19,778
$68,950
$15,281
$48,603
$15,418
Medicaid Business &
Policy
Behavioral Health
Children, Youth, & Families
Elderly & Adult Services
Public Health Services
Developmental Services
All Others
December 1, 2008 Dept of Health and Human Services 48
Health and MedicalBudget Highlights
Maintenance Medicaid Claims System SCHIP Pharmacy Services Provider Payments Breast and Cervical
Cancer Substance Abuse
Treatment Community Mental
Health
Change Provider Payments Regional Public Health Mental Health Plan Governor’s Commission TANF Family Planning
December 1, 2008 Dept of Health and Human Services 49
Long-Term CareBudget Highlights
Maintenance Nursing Services Older Americans Act Early Intervention DD Services
Change Eliminate budget
neutrality for nursing services
DD waitlist Wage parity for Direct
Service Professionals ABD waitlist College of Direct Support Family Supports
December 1, 2008 Dept of Health and Human Services 50
Human ServicesBudget Highlights
Maintenance Child protection Child and Family Services Child Development DJJS
Change TANF Delinquency
program Title IV-E TANF Rate increase Emergency Shelters
December 1, 2008 Dept of Health and Human Services 51
AdministrationBudget Highlights
Funding of all current positions Salary step increases Base salary increase reflecting full year cost of
1/2/09 current contract Benefits actual cost versus uniform percentage
December 1, 2008 Dept of Health and Human Services 52
Percentage IncreaseSFY10-11 vs SFY08-09
25.0% 25.0%
6.6%
11.9%
23.5%
10.5%10.8%
12.6%
0.0%
12.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Genl Fund Total FundsHealth & Medical Long Term Care Social ServicesAdministration Medicaid Enhancement
Percentages Represent Two-Year Totals
HMS LTCSOCIAL
ADMIN
HMS
LTCSOCIAL
ADMINDSHPSHREMQIP
December 1, 2008 Dept of Health and Human Services 53
About SFY 09
SFY 09 is a pivotal year and one that underscores a business as usual approach is not prudent Appropriation of $720M
Overview of Reductions Executive Order 2008-09 $14.8M HB 2 Administrative $2.5M Executive Order 2008-10 $25.36M Executive Order expected in near future
Tracking structural deficit of $8.9M After $12.5M outpatient rate reductions for non-CAH
December 1, 2008 Dept of Health and Human Services 54
Provider NetworksFinancial Health
Financial Indictors
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Per
cent
of R
even
ue
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
Day
s E
xpen
ses
Cash Flow Percent of Revenue 1.4% 5.7% 2.0% 6.1% 10.2%
Days Expenses in AvailableNet Assets
60.6 97.0 77.7 296.4 282.1
DDAA CMHC CHS CA HospitalNon CA Hospital
December 1, 2008 Dept of Health and Human Services 55
Approach to Governor’s PhaseZero-Base Approach
Stakeholder Councils
Program Budget
Population Segments
RegionalAssessments
Federal mandatesBlock GrantsState MandatesOptional ServicesAdmin
Class Summary
Women FunctionalNeedsChildren
Men Population
Current SpendingContractsSpending by ServiceProjections
Regional Listening
Community DialoguesAgenciesBoard ChairsConsumersElected Officials
Perspectives on Priorities
December 1, 2008 Dept of Health and Human Services 56
Turn Challenges to Opportunities
Commitment to soliciting stakeholder input to improve programs Transform the Medicaid program through the Medical Home Rebalance the Mental Health system with the 10-year plan Continue the transformation of the long-term care system through
stronger home and community based care network Streamline the operation starting with ACCESS Front Door
Build enabling IT infrastructure MMIS, New HEIGHTS, and NH FIRST
Vacancy management to enable maximum flexibility in staff deployment
Commit to LEAN and drive out costs that are unproductive or waste
December 1, 2008 Dept of Health and Human Services 57
Questions and Answer Session
Thank You