JAC Agency Hearings JAC Index 12-12-17am1 Tuesday December 12, 2017 Agenda: AM 048 – Department of Health 12/12/2017 8:02:35 AM Chairman of the Day: Chairman Nicholas Roll Call: Richards: Quorum is established Tom Forslund, Director Eric McVicker, Chief Financial Officer Forslund: Overview of DOH, impactful issues on budget, overview 19/20 exception requests, gained oversight on Department of Family Services, Korin Schmidt, interim director, 70 programs throughout the agency, 1413 positions authorized, DOH budget, 10% personnel, 90% payments to outside vendors /providers, very few payments to private individuals, issues – long term care costs, population aging, $130M/year to $312M by 2030, 5 factors: aging population with chronic disease, decrease working age adults to older individuals, higher costs of long term care, population ill prepared for long term care, small or weakening long term care market; overrun on Medicaid, budget overruns for 17/18, $32.14M overrun on Medicaid, 28M long term care costs from that, home and community based services growing, Medicare costs, dual eligible –both in Medicare and Medicaid at the same time, state gets the bill, part A,B,D; Governor cancelled a budget reduction in Medicaid, $1.5M Larsen: reduction breast and cervical cancer patients Forslund: given ability to move money around, GF loss, flexibility diminished, can no longer absorb overruns, $32M budget can absorb $10/11M not much more, Title 25 issues, $4.3M to state hospital, DOH access up to $10M from LSRA, $7.6M in title 25 costs – Dec 1, 2017; $5/6M decrease in cost, drop in commitments made in courts, community engagements, legislative changes, operational changes at state hospital, move billing to Medicaid billing department for state hospital, CHIP – health care for children too much money for Medicaid but not enough for private insurance, Fed 88%, states share- 12%, expired Nov 2107, not renewed, April 2018 WY runs out of money to fund this, DD rebasing of providers, preliminary cost estimates - $33M per biennium, half state GF, report forthcoming, management audit early education program, DOH not following funding model, external costs Larsen: external cost adjustments Forslund: funding model, ECA’s, 17/18 shortfall budget issues, 19/20 exceptions, h/o 078 overview Larsen: SSI vs state SSI supplemental payment, low income folks, declared eligible for health related payment costs, JAC/Legislature could adjust payment, Forslund: 100% state funded SSI –state, not enough money to process all the claims Dockstader: total $7M, no hidden fees Sommers: technology/ software systems, Fed provide 90% startup of system, pays 75% of costs going forward (management fees) Forslund: 19/20 exception requests – h/o 078, nursing home facilities – increased facilities, long term care – increased enrollment 12/12/2017 8:50:38 AM Larsen: long term care requirement Forslund; meet requirements to be in a nursing home, state has responsibility, home and community based services cheaper option, must meet requirements same as getting into a nursing home, legislature removed cap and trend going up for h/c based services Schwartz: numbers pg. 75 and 93 Landen: difficult position with l/c waivers, communities don’t have services, must move to bigger city to gain services needed Forslund: challenges w/I communities in having skilled labor force to support, need strategy for this aging Tsunami McVickers: creating demand Burns: population numbers pg. 75 and 93 Forslund: clarified costs per month $4,355/month nursing g home, costs Nicholas: alerting committee to shortfalls not in budget Landen: folks moving to WY, retired, increasing demand on services Forslund: shortfalls outlined, absorb what DOH can, need help from JAC, Medicare part A – dual eligible, overfunded in FF, h/o 078 Burns: computer replacement, ETS, 5 year replacement schedule, Forslund: 5 yr schedule on track, computer pricing remains, McVickers; thru ETS for costs Forslund: continuing h/o 078 Wilson: efficiency commission report suggested savings Forslund: CHIP and Medicaid program, Medicaid program cheaper, net savings but not for GF, Feds pay 88% for Medicaid, pay lesser amount for CHIP Nicholas: benefits modification help Forslund: benefits spelled out in state statute, kids are inexpensive to insure, lots of kids on Medicaid, Aged and Disabled more expensive, obviously, and cutting benefits not a huge gain Larsen: different options needed Forslund; at the mercy of private contractors, more expensive, directed by Legislature, h/o 078, public health – adolescent health, no GF available, community mental health Larsen: feds audit risk? Forslund: risk still there, review historical look, cut funds, h/o 078, drug courts, title 25 funding, state hospital equip replacement Sommers: % decrease in preschools? Report/ document outlining subject Forslund: statute has as one program, 2 programs, part b and part c, age split, increased in one not other Larsen: not total population? Forslund: delays and simply DD identified Hastert: counts vary depending upon date and one or two counts Forslund: moved up dates for count, give centers extra time, first year implemented, preschool external cost adjustment, should maybe in education but keep together Larsen: $33M? total dollars? Forslund: 19/20 budget, $237M serves 2K 12/12/2017 9:40:44 AM Break Nicholas calls committee back to order 12/12/2017 9:47:26 AM Eric McVicker, Chief Financial Officer starts walking through the budget Schwartz: are the monitors replaced along with the computer? McVicker: monitor replacement removed from the request Schwartz: fee structure? Korin Schmidt, Deputy Director: explains special revenue and fees Nicholas: how much money have we already removed? Forslund: $60 million in this program, a little over $100 total general funds removed Schwartz: CHIP program Larsen: Medicaid vs. CHIP Teri Green, State Medicaid Agent: income eligibility different for each program Forslund: Medicare Part D “clawback” Sommers: page 49 Schwartz: dual eligible and rate of increase? Burns: DFS payment and required statutory change Don Richards: that’s correct Hastert: how many people are served in this program? Forslund: approximately 3,500 Walters: further explanation on page 59 Forslund: provides explanation Nicholas: effective immediately or how will this work? Forslund: that’s a good conversation to have and I need help from the committee to determine the best way to handle it Sommers: what are the consequences of eliminating the SSI program? Forslund: you are effecting the lives of 3,500 low-income people and their families and the co-pays and medicine they use the money for. McVicker: page 66 320 exception request Wilson: what’s the thinking on this? Teri Green: provides explanation on payment structure for Pas Forslund: it goes back to the idea of expansion of care and trying to deliver services to all areas of Wyoming Sommers: what did the Medicaid Medical Advisory Group say about this proposed change? 12/12/2017 10:24:34 AM Nicholas: cost of nursing home care and how Wyoming compares to other states? Forslund: our costs compared to other states are high for aging population in particular Burkhart: Why are our costs so high? New Mexico example Forslund: this is something we consistently look at and not sure we have a great answer Larsen: does the governor still feel strongly about this cut? Forslund: yes, he is still of the same opinion Sommers: what if we change the poverty rate? Forslund: yes you can adjust that and it will have an impact Burns: what did the governor direct you to do here? Forslund: the governor felt as though this was a “bridge too far” Wilson: Medicaid Expansion/waivers etc.? Sommers: can you get me the poverty rates? Forslund: we will provide that to you and the committee 12/12/2017 10:46:04 AM Landen: waiting list? Forslund: the legislature removed the waiting list a few years ago. Remember, these are individuals who are eligible based on their physical conditions to be place in a nursing home. Nicholas: requests list of vaccinations Schwartz: VIP vs. VFC eligibility for vaccinations programs Forslund: biennial cut as it relates to maternal and child services, $400,000 Don Richards: provides explanation McVicker: page 137 WIC exception request Larsen: county reimbursement? Sommers: page 156 dollar figure associated with the elimination of the position? Vacancy list Forslund: uniqueness of health care providers; difficulty recruiting and retaining in part due to lower salaries than the private sector 12/12/2017 11:18:09 AM BREAK 12/12/2017 11:35:00 AM McVickers: pg. 160, Pyle: Ryan White, HIV positive, impact on fed $’s McVickers: pg. 165, 167, 170, 175, 179, Nicholas: report on impact on fed $’s McVickers: pg. 180 numbers got flipped, tobacco numbers $8M – 17/18 budgets, public health finished, pg. 183 Forslund: prevention challenges, return on investment, rates have decreased, results – immunization, smoking reduction can be tied to taxation and regulation, offer smoking cessation options, prevention doesn’t work take all the money out option Burns: trending is decrease in smoking, effect, $’s could be spent on other programs with a more immediate effect, i.e. long term care; effectiveness of prevention Forslund: policy impact through legislation McVickers: pg. 187, FF loss, restores appropriation Newman: BHD, block grants, maintenance of effort, exceptions Larsen: release funds to block grant Newman: yes Wilson: substance abuse, cuts to suicide prevention Forslund: $2M/year, cause and effect in different areas, smoking, drugs and alcohol, significant impact large amounts of people, suicide tremendous impact limited number, took a large cut from suicide prevention, one year contracts, broke contract into smaller parts, more competition, changing model Wilson: metric on trends? Forslund: yes, Sommers: money spent on suicide prevention requested; all counties included? Forslund: can provide, suicide not less important, reductions in funds driving focus, look at by county, money available will drive decision, talking to county commissioners McVickers: pg. 191 Forslund: take $1M out of reserves, cover a couple of years, underspending goes into reserve, and balance $4.8 M Schwartz; performance metrics for drug courts requested Landen: nonprofits efforts affected by funds decrease McVickers; pg. 196, Title 25, Gov’s rec $6M Nicholas: gatekeepers, various other ways to reduce burden on DOH, how do we keep it going? Forslund: trending with attention paid, Title 25 explanation, court commitments, system backs up, hospital contracts thru DOH, move billing to state hospital into Medicaid program billing, Title 25 beds being used by long term care individuals, plan is to move l/t care to suitable homes and free up beds for Title 25 individuals, gatekeeper program, counties have designated gatekeepers, great promise 12/12/2017 12:13:04 PM Schwartz: Title 7, criminally incompetent, initial evaluation at state hospital Forslund: evaluators travel, not always in area, backs up system Sommers: 2 or 3 things could legislature do to decrease Title 25 individuals cost Forslund: incentivize someone at local level to take ownership, no one is incentivized to not send to state hospital or get them out back to home community, local communities have no reason to keep them out of the system Forslund: pg. 200, use PLF McVickers: pg. 206, pg. 208 Newman: cuts implementation effect, flexibility within sections/units, treatment providers – community mental health, reductions GF, some received block grant Schwartz: reductions related to Title 25 increases Forslund: no McVickers: pg. 212 Larsen: FF used for incarcerated folk’s mental health issues, community mental health providers, will check Forslund: block grants to providers Newman: yes can use block grant McVickers: pg. 214 Forslund: annual child count, external cost adjustment impacts/application 12/12/2017 12:33:38 PM Lunch