State of New Hampshire Department of Health and Human Services

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State of New HampshireDepartment of Health and
Human Services

• Public Hearing on Budget Request
• Monday, December 1, 2008
• Commissioner Nick Toumpas

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Presentation Objectives

• Outline DHHS SFY 10/11 Maintenance and Change
  Budget Request
• Focus centered on big picture, not program or
  function specifics

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Todays Agenda

• Todays objectives
• DHHS profile, background and context
• External environment and assumptions
• DHHS Response
• Budget request overview
• Question and answer session

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Department of Health and Human ServicesProfileB
ackground Context
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Mission Statement

• To join communities and families in providing
  opportunities for citizens to achieve
• health and independence

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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 Hampshires most
  vulnerable citizens

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Guiding Principles

• Services
• Community based
• Family oriented
• Prevention oriented
• Crisis response
• Outcome based

• Operations
• Fiscal responsibility
• Workforce quality
• Management quality
• Information rich
• Open communications

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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

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Organization Structure
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The External Environment

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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

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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

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DHHS Challenges

• Increasing numbers and complexities of clients
• Cost of medical services
• Growing faster than inflation or State revenues
• Need for emergency planning
• Purchasing methodologies based too focused on
  cost
• Not enough on outcomes and improvements
• Litigation
• Federal/State/County/Local relationships
• Adapting organization to address increased
  demands
• With fewer resources
• Information technology-working with old
  technology

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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

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The DHHS Response

• Segment the populations we serve by primary need
• Underlying drivers in each segment require
  specific response

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DHHS Client CountsAs of September, 2008
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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

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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 Organizations
• American 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

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Stakeholder Council for Long-Term Care Services

• DHHS Program Units
• DCBCS-Bureau of Elderly Adult Services
• DCBCS-Bureau of Developmental Services
• Glencliff Home
• Stakeholder Organizations
• AARP, Brain Injury Association of NH, Council on
  Developmental Disabilities, CSNI, Dartmouth
  Medical School, Disability Rights Center,
  ENGAGING NH, Governors 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.

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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 Organizations
• Bonnie 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.

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Goal is greaterHealth Independence

• HEALTH INDEPENDENCE

Improvement
Safety Net
Health Medical Services
Long Term Care Services
Human Services
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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
• Childrens mental health

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Medicaid Medical Assistance
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SCHIP Enrollment and Average Cost
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Behavioral Health
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Public Health Primary Care
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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

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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

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Long Term CareDevelopmental Services
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Long Term Care ServicesMedicaid Elderly
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Trends In Long Term Care
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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.

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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

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Human ServicesAbuse Neglect
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Human ServicesTANF
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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

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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

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Overview of Departments Budget Request

• Agency Phase
• Maintenance and Change
• SFY 10 and SFY 11

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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

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Provider Rate Increases Maintenance Change
Budget
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Budget byExpense Class
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Dept of Health and Human ServicesAgency Request

•  

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Maintenance RequestTotal Funds SFY 10/11
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Maintenance RequestTotal Funds SFY 10/11
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Maintenance RequestGeneral Funds SFY 10/11
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Maintenance RequestGeneral Funds SFY10/11
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Change Budget RequestGeneral Funds SFY 10/11
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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
• Governors Commission
• TANF Family Planning

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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

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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

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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

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Percentage IncreaseSFY10-11 vs SFY08-09
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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

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Provider NetworksFinancial Health
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Approach to Governors PhaseZero-Base Approach
Stakeholder Councils
Program Budget
Population Segments
Regional Assessments
Regional Listening
Federal mandates Block Grants State
Mandates Optional Services Admin Class Summary
Women Functional Needs Children Men
Population
Current Spending Contracts Spending by
Service Projections
Community Dialogues Agencies Board
Chairs Consumers Elected Officials
Perspectives on Priorities
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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

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Questions and Answer Session

• Thank You