State of New Hampshire Department of Health and Human Services

1. 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

2. 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

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 Dept of Health and Human Services

4. Department of Health and Human ServicesProfileBackground Context Dept of Health and Human Services

5. Mission Statement “To join communities and families in providing opportunities for citizens to achieve health and independence” 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 Dept of Health and Human Services

7. 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

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 Dept of Health and Human Services

9. Organization Structure Dept of Health and Human Services

10. The External Environment 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 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 Dept of Health and Human Services

13. 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

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 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 Dept of Health and Human Services

16. DHHS Client CountsAs of September, 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 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 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

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 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

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 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

21. Goal is greaterHealth & Independence HEALTH & INDEPENDENCE Improvement Safety Net Health & Medical Services Long Term Care Services Human Services 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 Dept of Health and Human Services

23. Medicaid Medical Assistance Dept of Health and Human Services

24. SCHIP Enrollment and Average Cost Dept of Health and Human Services

25. Behavioral Health Dept of Health and Human Services

26. Public Health Primary Care 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” 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 Dept of Health and Human Services

29. Long Term CareDevelopmental Services Dept of Health and Human Services

30. Long Term Care ServicesMedicaid Elderly Dept of Health and Human Services

31. Trends In Long Term Care 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. 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 Dept of Health and Human Services

34. Human ServicesAbuse & Neglect Dept of Health and Human Services

35. Human ServicesTANF 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 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 Dept of Health and Human Services

38. Overview of Department’s Budget Request Agency Phase Maintenance and Change SFY 10 and SFY 11 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 Dept of Health and Human Services

40. Provider Rate Increases Maintenance & Change Budget Dept of Health and Human Services

41. Budget byExpense Class Dept of Health and Human Services

42. Dept of Health and Human ServicesAgency Request Dept of Health and Human Services

43. Maintenance RequestTotal Funds SFY 10/11 Dept of Health and Human Services

44. Maintenance RequestTotal Funds SFY 10/11 Dept of Health and Human Services

45. Maintenance RequestGeneral Funds SFY 10/11 Dept of Health and Human Services

46. Maintenance RequestGeneral Funds SFY10/11 Dept of Health and Human Services

47. Change Budget RequestGeneral Funds SFY 10/11 Dept of Health and Human Services

48. 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

49. 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

50. 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