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State of New Hampshire Department of Health and Human Services. Public Hearing on Budget Request Monday, December 1, 2008 Commissioner Nick Toumpas. Presentation Objectives. Outline DHHS SFY 10/11 Maintenance and Change Budget Request

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State of new hampshire department of health and human services

State of New HampshireDepartment of Health and Human Services

Public Hearing on Budget Request

Monday, December 1, 2008

Commissioner Nick Toumpas

Dept of Health and Human Services


Presentation objectives

Presentation Objectives

  • Outline DHHS SFY 10/11 Maintenance and Change Budget Request

  • Focus centered on big picture, not program or function specifics

Dept of Health and Human Services


Today s agenda

Today’s Agenda

  • Today’s objectives

  • DHHS profile, background and context

  • External environment and assumptions

  • DHHS Response

  • Budget request overview

  • Question and answer session

Dept of Health and Human Services


Department of health and human services profile background context

Department of Health and Human ServicesProfileBackground Context

Dept of Health and Human Services


Mission statement

Mission Statement

“To join communities and families in providing opportunities for citizens to achieve

health and independence”

Dept of Health and Human Services


Responsibilities

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

Dept of Health and Human Services


Guiding principles

Services

Community based

Family oriented

Prevention oriented

Crisis response

Outcome based

Operations

Fiscal responsibility

Workforce quality

Management quality

Information rich

Open communications

Guiding Principles

Dept of Health and Human Services


Department profile

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

Dept of Health and Human Services


Organization structure

Organization Structure

Dept of Health and Human Services


The external environment

The External Environment

Dept of Health and Human Services


Citizen expectations

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

Dept of Health and Human Services


The perfect storm

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

Dept of Health and Human Services


Dhhs challenges

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

Dept of Health and Human Services


Assumptions for budget development

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 IndexSFY10-5.5%, SFY11-5.0%

    • · Utilities/Energy SFY10-20.0%, SFY11-5.0%

    • · TravelSFY10-16.0%, SFY11-5.0%

    • ·  MedicalSFY10-4.1%, SFY11-4.1%

  • Caseload Increases

    • Maintenance budget includes anticipated growth in caseloads in entitlement programs.

    • Caseload growth for non-entitlement programs budgeted in Change

Dept of Health and Human Services


The dhhs response

The DHHS Response

Segment the populations we serve by primary need

Underlying drivers in each segment require specific response

Dept of Health and Human Services


Dhhs client counts as of september 2008

DHHS Client CountsAs of September, 2008

Dept of Health and Human Services


Need based segmentation

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

Dept of Health and Human Services


Stakeholder council for health medical services

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…

Dept of Health and Human Services


Stakeholder council for long term care services

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, 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….

Dept of Health and Human Services


Stakeholder council for human services

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….

Dept of Health and Human Services


Goal is greater health independence

Goal is greaterHealth & Independence

HEALTH & INDEPENDENCE

Improvement

Safety Net

Health & Medical Services

Long Term Care Services

Human Services

Dept of Health and Human Services


Health and medical

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

Dept of Health and Human Services


Medicaid medical assistance

Medicaid Medical Assistance

Dept of Health and Human Services


Schip enrollment and average cost

SCHIP Enrollment and Average Cost

Dept of Health and Human Services


Behavioral health

Behavioral Health

Dept of Health and Human Services


Public health primary care

Public Health Primary Care

Dept of Health and Human Services


Health and medical distribution system

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”

Dept of Health and Human Services


Long term care

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

Dept of Health and Human Services


Long term care developmental services

Long Term CareDevelopmental Services

Dept of Health and Human Services


Long term care services medicaid elderly

Long Term Care ServicesMedicaid Elderly

Dept of Health and Human Services


Trends in long term care

Trends In Long Term Care

Dept of Health and Human Services


Long term care distribution system

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.

Dept of Health and Human Services


Human services

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

Dept of Health and Human Services


Human services abuse neglect

Human ServicesAbuse & Neglect

Dept of Health and Human Services


Human services tanf

Human ServicesTANF

Dept of Health and Human Services


Human services distribution system

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

Dept of Health and Human Services


Dhhs administrative oversight support

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

Dept of Health and Human Services


Overview of department s budget request

Overview of Department’s Budget Request

Agency Phase

Maintenance and Change

SFY 10 and SFY 11

Dept of Health and Human Services


Budget development influences

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

Dept of Health and Human Services


Provider rate increases maintenance change budget

Provider Rate Increases Maintenance & Change Budget

Dept of Health and Human Services


Budget by expense class

Budget byExpense Class

Dept of Health and Human Services


Dept of health and human services agency request

Dept of Health and Human ServicesAgency Request

Dept of Health and Human Services


Maintenance request total funds sfy 10 11

Maintenance RequestTotal Funds SFY 10/11

Dept of Health and Human Services


Maintenance request total funds sfy 10 111

Maintenance RequestTotal Funds SFY 10/11

Dept of Health and Human Services


Maintenance request general funds sfy 10 11

Maintenance RequestGeneral Funds SFY 10/11

Dept of Health and Human Services


Maintenance request general funds sfy10 11

Maintenance RequestGeneral Funds SFY10/11

Dept of Health and Human Services


Change budget request general funds sfy 10 11

Change Budget RequestGeneral Funds SFY 10/11

Dept of Health and Human Services


Health and medical budget 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

Health and MedicalBudget Highlights

Dept of Health and Human Services


Long term care budget 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

Long-Term CareBudget Highlights

Dept of Health and Human Services


Human services budget highlights

Maintenance

Child protection

Child and Family Services

Child Development

DJJS

Change

TANF Delinquency program

Title IV-E

TANF Rate increase

Emergency Shelters

Human ServicesBudget Highlights

Dept of Health and Human Services


Administration budget highlights

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

Dept of Health and Human Services


Percentage increase sfy10 11 vs sfy08 09

Percentage IncreaseSFY10-11 vs SFY08-09

Dept of Health and Human Services


About sfy 09

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

Dept of Health and Human Services


Provider networks financial health

Provider NetworksFinancial Health

Dept of Health and Human Services


Approach to governor s phase zero base approach

Approach to Governor’s 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 FunctionalNeeds

Children

Men

Population

Current Spending

Contracts

Spending by Service

Projections

Community Dialogues

Agencies

Board Chairs

Consumers

Elected Officials

Perspectives on Priorities

Dept of Health and Human Services


Turn challenges to opportunities

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

Dept of Health and Human Services


Questions and answer session

Questions and Answer Session

Thank You

Dept of Health and Human Services


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