File name: JAC Budget Hearings FY 13-14_20120117_080051.dcr Folder: C:\Documents and Settings\HAppropriations\Desktop\Recordings 3 ~ 1/17/2012 8:19:42 AM ~ Tuesday January 17, 2012 Department of Health 1:22 ~ 1/17/2012 8:21:00 AM ~ Berger: Agency 48, Tom Forslund, New Director 2:51 ~ 1/17/2012 8:22:29 AM ~ Mai: Life Resource Center; Agreement with CMS and the way medicare works. ICMFR monies. Dept has to change the way the money is carried forward. Budget document looks accurate, never came off the profitle so documents from Governor overstated revenues. Next profile will reflect 21 million not being available. 4:40 ~ 1/17/2012 8:24:18 AM ~ Nicholas: CIO issue, 4:48 ~ 1/17/2012 8:24:27 AM ~ Mai: CIO issues, billing for their services, If we go with current plan, CIO and A&I call back on Monday, see another hit of about 4 million to the GF. 51 million underwater in Gov rec. Expenses for services billed back from the Federal Goft. Giving up current funding model. Appropriate GF monies to agencies and they use it to leverage matching funds. Pay back lump in form of internal service transfers. In 306 budget, proposed to get away from that. Have to give up 13/14 funds, will not have ability tro leverage those funds, not going to approproate funds. 15/16 get back to square one. 7:34 ~ 1/17/2012 8:27:12 AM ~ Nicholas: Defering revenue or losing it. 7:43 ~ 1/17/2012 8:27:21 AM ~ Mai: Cost, not fully reflected on this profile, information and summaries. Best guess of 4 million dollars. Profile Gov's rec that way he will be 52 million under water. 8:33 ~ 1/17/2012 8:28:11 AM ~ Nicholas: Goldenrod, closer to 52 million underwater. 8:56 ~ 1/17/2012 8:28:34 AM ~ Berger: Start hearing 9:06 ~ 1/17/2012 8:28:44 AM ~ Forslund: Introductions: Bob Peck, Wendy Brauhm, Chris Newman, Terry Green, April Getchus, Meredith Hasty. Bob Peck will assist. 11:16 ~ 1/17/2012 8:30:55 AM ~ Forslund: Overview of changes and initiatives: Handout 144 has information and will reference it. Reorganization, review of divisions with history of budget growth, performance management initiative, current 11/12 budget, overview of 13/14 budget 12:31 ~ 1/17/2012 8:32:09 AM ~ Forslund: Reorganization of department: Review and restructuring, Page 1 and 2 of Handout, Page 1 as it exist today. Philosophy flatten the org. structure, to approve access to directors, align functions, break down silos which were created because of org structure and federal grants, break down silos to address complex issue sacross lines. Director office and 4 divisions. 14:52 ~ 1/17/2012 8:34:30 AM ~ ForslundL Handout pg 3, first block for department funding of GF and federal fund. Middle block shows standard budget growth, federal, state and other. Fourth block is authorized divisions. Last block shows where the growth has occurred. Ex: Director's office 12 million. Total of 521.6 million. leads to middle chart of 521.6 on total budget, total growth. 17:22 ~ 1/17/2012 8:37:00 AM ~ Forslund: Handout, page 4 Director's office total growth 12 million. 11.7 million from GF. Growth in positions was in 11/12 because of consolidation of IT in one budget group. 7.4 growth from tax refund funding through HB 238. Consolidation of d 18:39 ~ 1/17/2012 8:38:17 AM ~ Nicholas: HB 238 ? 18:46 ~ 1/17/2012 8:38:25 AM ~ Peck: 4 years ago, raised the income limits and refunds limits. Increased income by almost 50%. maxium refund increased from 800 to 900 for married and raised for single. 19:29 ~ 1/17/2012 8:39:07 AM ~ Nicholas: ? 19:32 ~ 1/17/2012 8:39:10 AM ~ Peck: Refund of property, utility and sales tax es. 20:06 ~ 1/17/2012 8:39:44 AM ~ Forslund: Director's office, Fiscal services in directors office now, were located throughout the agency. New office of health policy and evaluations. Three legislative studies pending. Cost study is estimating cost of new medicaid part, second to improve costs, third to reorganize dept of health. The 100,000 appropraited for study to reorganize not needed. Offered money for study of options. 22:20 ~ 1/17/2012 8:41:59 AM ~ Forslund: Handout pg 5, Medicare waivers and CHIP. Terry Green and Roxanne Homar. Medicaid overall is large program. 22:52 ~ 1/17/2012 8:42:31 AM ~ Berger: 22:55 ~ 1/17/2012 8:42:33 AM ~ VonFlatern: ON director's office and health care finance, do not add across to get total cost. What does it mean? 23:25 ~ 1/17/2012 8:43:03 AM ~ Forslund: Start at 9.8 and it is currently at 21.8 so there is a 12 million growth from base of 2007-2008. 24:02 ~ 1/17/2012 8:43:41 AM ~ Forslund: Medicaid: People frustrated with cost. Looking at what we can do with Medicaid and medicaid cost. Have to better define problems and understand issues. EX: Understand cost drivers. Need to understand how to control cost. Doing data mining. Example on page 6. 95/5 recipent analysis. First line which says adult, 20577 costing 2421 dollars per person per year, approximately 50 millin in costs for those 21,000 people. That is bottom 95% of group. Top 5% has 1082 people with avg cost of 29,615 per person for 32 millin for the group. Most expensive people are disabled group, cost is 15,000 per person per year. On top side 500 people are cosing 63 million per year. For us to try to control cost, example children's side, could spend time to control it but at 1209 per year, will not have significant impact compared to higher cost areas. Can you do anything? Some yes, some no. Exploring where opportunities and costs are. 28:58 ~ 1/17/2012 8:48:36 AM ~ Von Flatern: State only or combined? 29:08 ~ 1/17/2012 8:48:46 AM ~ Forslund: Total cost which is comvined, 50/50. 29:24 ~ 1/17/2012 8:49:02 AM ~ Meier: Enrollment? 29:31 ~ 1/17/2012 8:49:10 AM ~ Forslund: Large increase in number of people coming on program in recent years, has driven cost of Medicaid program. Look at how high cost they are. Pent up demand at first, spike costs, then level off. If people are in top 5% will keep it up there. Direct correlation between unemployment rate in state and enrollment in medicaid. When unemployment rate drops, not necessarily seeing drop in people on medicaid roles. 31:21 ~ 1/17/2012 8:50:59 AM ~ Meier: Relationship between DFS and your department for eligibility requirements. DFS looks at eligibility on annual basis, hoping to get it down to 6 months. Eligibility criteria protocal down to 6 months. When they get job, be checked out t osee if they are eligible. 32:22 ~ 1/17/2012 8:52:01 AM ~ Forslund: Federal law will not allow us to drop it to less than a year at this time. We can not make it more restrictive for a period of years. Maintenance of Effort. Can not make that change in the next few years. 33:13 ~ 1/17/2012 8:52:51 AM ~ Hastert: Other Medicaid services of 43 million, examples of other? 33:33 ~ 1/17/2012 8:53:11 AM ~ Forslund: 40 items, pharmacuticals, mental health services,. 34:04 ~ 1/17/2012 8:53:43 AM ~ Edmonds: Discussion on enrollment year ago. Locked down becasue we took ARRA funds? 34:29 ~ 1/17/2012 8:54:07 AM ~ Forslund: yes, when state agreed to take ARRA funding, this was one of stipulations that took place, into 2019 for children and 2016 for adults. 35:10 ~ 1/17/2012 8:54:48 AM ~ Wallis: Consequences if we established a different maintenance of effort. To maintain budget, it is necessary for us to make sure poepl receiving benefits are eligible, just do it. 35:44 ~ 1/17/2012 8:55:22 AM ~ Forslund: probably every state in country has that issue, most in worse financial condition than Wyoming. No state has taken risk to say we have to make that change. If federal govt would reduce or eliminate medicaid match, do not know. Putting 500 million of matching money at risk. 36:39 ~ 1/17/2012 8:56:17 AM ~ Nicholas: Numbers up during unemployment and not seeing drop off, eligibility test in 6 months would make a difference. Woudl have to test thesis. Are these people opting out to go into educational opportunites, do we know what is happening. People going on medicaid and never coming off? 38:09 ~ 1/17/2012 8:57:47 AM ~ Forlund: Do not know. Human dynamics that impact program. To test that, have to implement different initiatives that currently we can not do. Could do random sampling and talk to people. 38:54 ~ 1/17/2012 8:58:32 AM ~ Nicholas: means tested, could have jobs and be eligible, could go to college and continue eligibility, so off rolls of unemployed but still eligible. That data ought to be available through A&I or something. Data should be available. What would it take to find out? 39:49 ~ 1/17/2012 8:59:27 AM ~ Forslund: STate does not have tremendous amount or ability to do data mining. I have more questions than what I can get answers for. Get antedotal but not data. What is it going to take? Beef up our technological capabiliteis and internal expertise within department to do data analysis. 41:24 ~ 1/17/2012 9:01:02 AM ~ Nicholas: Billion dollar budget, cost increases we can not control, 10 years of questions with unacceptable answers or not available. Take more people and dollars? If you want help, give us a budget and plan to change that. Tell us exactly what it will cost you to get that informatin so you can get answers. 42:51 ~ 1/17/2012 9:02:29 AM ~ Forslund: Invitation to provide recommendations to you. / 44:43 ~ 1/17/2012 9:04:21 AM ~ Berger We do go through optional waivers. 44:58 ~ 1/17/2012 9:04:36 AM ~ Forslund Not only are they not interested in cutting, they want to add to it 45:27 ~ 1/17/2012 9:05:05 AM ~ Wallis: 30 years ago I was a single mom with 3 kids. If I changed jobs, I was required to report that immediately.. In that case, why can't we take a good hard look at those changing circumstanses. 47:08 ~ 1/17/2012 9:06:46 AM ~ Forslund The feds says we can't change the rules 47:42 ~ 1/17/2012 9:07:20 AM ~ Nicholas: That would be falsesly declaring employment 48:37 ~ 1/17/2012 9:08:15 AM ~ Edmonds How vigoresly do we investigate cases 49:07 ~ 1/17/2012 9:08:45 AM ~ Forslund The AG's office looks into that. There was a case in the paper the other day but you don't see very many of them. 50:11 ~ 1/17/2012 9:09:49 AM ~ Green: That process is called eligibility and fraud control. We have not been happy with that process and we have asked to take that over. That does not mean if they get a job, they do not have to declare that. It states in there that those funds are in jeopordy if we make e 53:07 ~ 1/17/2012 9:12:45 AM ~ Edmonds: Do you have what the total match is 53:34 ~ 1/17/2012 9:13:12 AM ~ Peck $125,000,000 53:49 ~ 1/17/2012 9:13:28 AM ~ Green All kinds of income 54:04 ~ 1/17/2012 9:13:42 AM ~ Esquibel: I'm assume those social security are on the form when they fill out an application for benefits 54:48 ~ 1/17/2012 9:14:27 AM ~ Pedersen When we expand our eligibility Last year we could have expanded medicare dollars ARRA funds. 56:05 ~ 1/17/2012 9:15:43 AM ~ Green: The only funds I am aware of is the....... We have very small 56:47 ~ 1/17/2012 9:16:25 AM ~ Nicholas I remember when the ARRA funds were created,..... While some folks don't report that they got a job, I think they are very few. It's against the law, they could go to jail. The argument is if you qualify you need to get those benefits. Life styles have changed. If the women have children and get married, they go off the roles. Now they just live with their boyfriends and never get married and don't drop off program. 1:00:50 ~ 1/17/2012 9:20:28 AM ~ Forslund: We can not drop a program arbitrarily. 1:01:22 ~ 1/17/2012 9:21:00 AM ~ Nicholas: If we can't afford, that is arbitrary? 1:01:42 ~ 1/17/2012 9:21:21 AM ~ Green: Two things There are certain things that are optional and required. Medical is not optional. Optional waivers can expire 1:03:14 ~ 1/17/2012 9:22:52 AM ~ Nicholas Are there wiever programs that can expire? 1:03:37 ~ 1/17/2012 9:23:15 AM ~ Green: Yes, there are 1:03:48 ~ 1/17/2012 9:23:26 AM ~ Newman: This wairver expires in 2016 1:04:30 ~ 1/17/2012 9:24:08 AM ~ Nicholas: Dr. Miley said that we would regret the day we adopted this program. 1:05:09 ~ 1/17/2012 9:24:47 AM ~ Newman: When a person is declaried financially eligiable, they are.....AS with all el 1:06:02 ~ 1/17/2012 9:25:40 AM ~ Nicholas What does the ADI cover? 1:06:24 ~ 1/17/2012 9:26:03 AM ~ Green Specifically to the brain damage services, they try to get them to redevolpe those skills. 1:07:10 ~ 1/17/2012 9:26:48 AM ~ Nicholas: What percentage are accidents without seatbelts 1:07:42 ~ 1/17/2012 9:27:20 AM ~ Steward Poverty level is a requirement for eligibility. 1:08:19 ~ 1/17/2012 9:27:58 AM ~ Green: We have not expanded any of our programs 1:08:41 ~ 1/17/2012 9:28:19 AM ~ Nicholas 1:08:57 ~ 1/17/2012 9:28:35 AM ~ Green: I don't believe we have that info 1:09:10 ~ 1/17/2012 9:28:48 AM ~ Meier: Looking at reducing costs Could we limit our costs to $100,000 1:09:57 ~ 1/17/2012 9:29:35 AM ~ Green: No, we have to provide what ever the needs are 1:10:15 ~ 1/17/2012 9:29:54 AM ~ Meier: That's ADI and disabled 1:10:40 ~ 1/17/2012 9:30:18 AM ~ Green: We have taken an indepth look those costs. 1:11:14 ~ 1/17/2012 9:30:52 AM ~ Esquibel: Page 6 graph Which box would medicare births fall? 1:11:47 ~ 1/17/2012 9:31:25 AM ~ Green If the child is born this problems, those problems are taken care of. 1:12:40 ~ 1/17/2012 9:32:18 AM ~ Forslund Page 7, Public Health Division Page 8 Behavioral Health Division 1:14:14 ~ 1/17/2012 9:33:52 AM ~ Meier When I renewed my insurance it required .... 1:14:46 ~ 1/17/2012 9:34:24 AM ~ Forslaund: That is an interesting question: We have talked about insurance pay for mental health issues. That is a public policy call. 1:15:44 ~ 1/17/2012 9:35:22 AM ~ Meier Socialized Mental health program here in Wyoming. Do we plug on all these mental health issues 1:16:32 ~ 1/17/2012 9:36:10 AM ~ Nicholas Bottom of Page 8 Bills 1:16:54 ~ 1/17/2012 9:36:32 AM ~ Forslund Those are mental health 1:17:11 ~ 1/17/2012 9:36:50 AM ~ Nicholas What 1:17:23 ~ 1/17/2012 9:37:01 AM ~ Peck Statuts require us to prepare and exceptional request for those centers across the state 1:18:06 ~ 1/17/2012 9:37:44 AM ~ Nicholas Each one these statutes is the result of a spectial committee. If you take out the monies for each of these special committees. Bill Mai can you do that. Let's see if we can't do that. Select committees for program expansion. 1:20:25 ~ 1/17/2012 9:40:03 AM ~ Wallis Went through the mental exercise Can we figure out if there is a correlation between kids 1:21:17 ~ 1/17/2012 9:40:55 AM ~ Berger: With that we will take a 10 minute break. 1:21:50 ~ 1/17/2012 9:58:11 AM ~ 1:21:54 ~ 1/17/2012 9:58:15 AM ~ Forsland: State of Wyoming spends Out of home placements 1:23:06 ~ 1/17/2012 9:59:27 AM ~ Nicholas: When we identify services is the cost covered in different parts........ or are there enough people? 1:24:40 ~ 1/17/2012 10:01:01 AM ~ Forslund: Regional system. State has gone into contracting with these Regional systems. Provide on need . As state puts more and more funds into mental health system, we have more than doubled what the state puts in What are the outcome measures 1:27:01 ~ 1/17/2012 10:03:22 AM ~ Nicholas: Is it comparable to other states? Is cost per capita the same as other states? The lack of taxes (personal income) or that our budget isn't as large as in other states?. What is ours compared to others 1:29:34 ~ 1/17/2012 10:05:55 AM ~ Forslund: We can compare and provide information to committee 1:30:01 ~ 1/17/2012 10:06:22 AM ~ Nicholas: Here is our budget and here are other states per capita --what is that comparasion? 1:30:54 ~ 1/17/2012 10:07:15 AM ~ Forslund: We have a growth in medicade area in mental health.General funds have gone up here. We are looking at Missouri model to see how that works. We willl get some information on that. 1:32:57 ~ 1/17/2012 10:09:18 AM ~ Nicholas: 50 million over budget and your agency has the ability to cut from your budget. If we flat line you .you will lower your reinbursement. There's still money going out to the community 1:35:17 ~ 1/17/2012 10:11:38 AM ~ Forslund: We will spend whatever you give us. We will manage. I can't give you 50 million but I can give you 10 million. I need flexibility. I think I have some savings I can use. I don't need the money for positions like I do for services 1:37:18 ~ 1/17/2012 10:13:39 AM ~ Nicholas; Positions were there that weren't needed. It's okay to give up vacancies. FTE's. If you keep those vacanacies but don't give up the money, that is a discussions we've alway been ready to have. Deal with our issures. 1:38:50 ~ 1/17/2012 10:15:11 AM ~ Forslund: We will have those discussions 1:39:08 ~ 1/17/2012 10:15:29 AM ~ Steward: How do we know how to manage these community based units? 1:40:23 ~ 1/17/2012 10:16:44 AM ~ Forslund: We are trying to simplify Is a person staying away from law enforcement or are they homeless. Are they ending up at the state hospital? They are too complicated the way we try to determine if it is successful or the outcomes aren't. 1:42:30 ~ 1/17/2012 10:18:51 AM ~ Steward: We hear that it take time to get this information. We seem to changes horses in the middle of the stream. Should we maintain our way of collecting information? 1:43:37 ~ 1/17/2012 10:19:58 AM ~ Forslund: I still think preformance based is best. 1:44:07 ~ 1/17/2012 10:20:28 AM ~ Nicholas: Look on page 7. Look at the percentage increase. 1:44:39 ~ 1/17/2012 10:21:00 AM ~ Peck: Over all percent is 10 percent........... and then 5 percent 1:45:14 ~ 1/17/2012 10:21:35 AM ~ Peck: Correct 1:45:36 ~ 1/17/2012 10:21:57 AM ~ Nicholas: When you give us these by percent, what is the breakdown for each catagory. Helpful to have percent of increase you have given. 1:46:56 ~ 1/17/2012 10:23:17 AM ~ Mai: page 7: That 21 percent increase in general fund is going to be 21 million . 1:47:44 ~ 1/17/2012 10:24:05 AM ~ Nicholas: 7% percent total budget.....? 1:48:18 ~ 1/17/2012 10:24:39 AM ~ Mai: Not an error. It was the way profiled Doesn't show percent reduction Page 10. 1:49:24 ~ 1/17/2012 10:25:45 AM ~ Nicholas Page 7 That is not profiled on this sheet yet you are telling me 21 million less. 1:50:09 ~ 1/17/2012 10:26:30 AM ~ Mai: I am wrong. 1:50:33 ~ 1/17/2012 10:26:54 AM ~ Nicholas: Need new page 7. 1:50:38 ~ 1/17/2012 10:26:59 AM ~ Mai: It is correct. 1:50:46 ~ 1/17/2012 10:27:07 AM ~ Nicholas: Did not make it to Goldenrod 1:50:58 ~ 1/17/2012 10:27:19 AM ~ Mai: Half of it is wrong 1:51:05 ~ 1/17/2012 10:27:26 AM ~ Nicholas: Blame Bret; Once we agree on profile, need spreadsheet showing % inc. of GF and federal funds requested by exception request you made and Gov's rec. Some programs asking 7 or 10%. Want charts built. 1:52:04 ~ 1/17/2012 10:28:25 AM ~ Peck: Have spreadsheet with all of that, need to add %'s. 1:52:21 ~ 1/17/2012 10:28:42 AM ~ Nicholas:? 1:52:24 ~ 1/17/2012 10:28:45 AM ~ Peck: Version is in packet, does not have Gov rec in it. 1:52:39 ~ 1/17/2012 10:29:00 AM ~ Nicholas: page? 1:52:44 ~ 1/17/2012 10:29:05 AM ~ Peck: will provide spreadsheet tomorrow 1:52:51 ~ 1/17/2012 10:29:12 AM ~ Nicholas: Email it, excell 1:52:58 ~ 1/17/2012 10:29:19 AM ~ Peck, excell, will email 1:53:05 ~ 1/17/2012 10:29:26 AM ~ Forslund: Pag 9 Aging Division, Pioneer Home, Veteran's Home, Wyoming Retirement Center Monthly operation reports: Handout 151 shows example of operation reports put into place and how used. State Hospital for Dec: avg waiting list, avg days waiting, 18 down to 10. Waiting to get into state hospital, paying to house in other locations. 271,000 expense, Monitoring that to get waiting times down to drop costs. Cost of care per patient per day: Current is 941, last month is 1020. Too high. Benchmarking against other state facilities and private providers, Variety of reasons for higher costs, part structural, part way we operate. 1:55:53 ~ 1/17/2012 10:32:14 AM ~ Forslund Handout pg 11 and 12: patterned afte Maryland and New York State: Tool to evaluate performance within department (of programs). Systematic, measurable. Pg 12, inputs of staffing and expenditures: Efficienty and outcome . Initiatives within the departmetn 1:57:10 ~ 1/17/2012 10:33:31 AM ~ Forslund: Status of 11/12 budget: 21 million deficiet in medicaid. 49 million in ARRA funding, ended 7 July of lat year, temporary funding that went away, lost 49 million as of July. Estimate end of year with 9 million deficet in GF medicaid. Hope to bring dept budget under authorized appropriation. 1:58:30 ~ 1/17/2012 10:34:51 AM ~ Nicholas: If we recommend lower than requested amount, you will trim burn rate. Trim reimbursement rates, impact on providers who will contact us, consequence we accept. You predict where you will be, trim your expenditures, your profile is a 9 million dollar deficiet. Discussion of how we stop having a burn rate that results in a deficiet? 1:59:59 ~ 1/17/2012 10:36:20 AM ~ Forslund: Start year 20 millino in hole, here is appropriation but it is 20 million short, can never get out of debt. Need to start from ground zero. Started at 20 in hole, 9 million for medicaid. For the dept, dug ourselves out. Would help if we did not start new biennium in the hole. We will adjust our spending accordingly to the money you give. 2:01:18 ~ 1/17/2012 10:37:39 AM ~ Nicholas: Flatline last year's budget, no budget exc. requests, you are saying if you are going to restrict your growth , need 9 million to pick up your deficiet.? 2:01:56 ~ 1/17/2012 10:38:17 AM ~ Forslund: Difficult for agency given budget with spending amount and it is really not there. So give us the dollaramount and we will live with it. 2:02:41 ~ 1/17/2012 10:39:02 AM ~ Nicholas: Total request of 52 million in GF, not your request, it is gov rec. ....you need to make up 9 million. Total of 100 million, about 10%. Have to make up 10 million as yiou go along. For every dollar reduced below gov rec still have 9 million to make up. 2:03:56 ~ 1/17/2012 10:40:17 AM ~ Pedersen: Burn rate: Start in hole,. Series of factors must be out of your control to impact burn rate. What factors are out of your control? 2:04:44 ~ 1/17/2012 10:41:05 AM ~ Forslund: Medicaid program is living within the budget appropriated, would be running a surplus if we did not start bieenium with 20 millin that must be paid back. Going in a positive direction this last 18 mnths in terms of spending. What controls spending? # of jpeople on program, type of services need, rates reimburse the providers. We can't control # of people as an agency. Legislature can control a protion by waivers. Medicaid and waivers are the same thing. Other than wiavers, people on program meet qualifiecatons, can not control. Have need are allowed to get services. Deal with it with long term changes. Provider rates can turn on a dime, reduce or adjust amounts paid. Dept has had to deal with that when dealing with cuts in past. 2:07:41 ~ 1/17/2012 10:44:02 AM ~ Meier: % provider reimbursement of the total cost of the Medicaid program. 2:08:00 ~ 1/17/2012 10:44:21 AM ~ Forslund: approximately 95% 2:08:07 ~ 1/17/2012 10:44:28 AM ~ Meier: To reduce 10%m reduce providers rate by 10%, reduces total cost of program 2:08:29 ~ 1/17/2012 10:44:50 AM ~ Forslund: correct 2:08:35 ~ 1/17/2012 10:44:56 AM ~ Nicholas: Three factors and starting in hole wiht 20 million. Can not remember budgeting a deficiet. Deficiets arose from reimbursment rates or managment. ARRA funds amount? 2:09:18 ~ 1/17/2012 10:45:39 AM ~ Forslund 49 million in ARRA. 2:09:25 ~ 1/17/2012 10:45:46 AM ~ Nicholas: We budgeted an amount at beginning of biennium, then told would run out in April because of burn rate, provide us more money. Variable factors, 20 million deficiet, not waht we have budgeted. Have a burn rate to predict to get to a balanced budget. We see that it makes no difference what we appropriate, you burn at a rate that is comfortable. How do we avoid that? 2:10:51 ~ 1/17/2012 10:47:12 AM ~ Forslund: How do you control a cost of a program, in a way that is acceptable to the constituents? Number of viewpoints: intent of program, a safety net for lowest % of people or beyond that. In wyoming it is beyond safety net for lowest income in the state. Variable beyond dept control are economy, How do you better run program to address all the interests? If issue is simply cost, we can cut 25% out of medicaid just like that, would take away the optional services the legislature has said we want to add. 25% of a billion dollars is big bucks. Tremendous impact. People say it is off limits, More of a challenge for the Dept. to administer. Areas can be improved. Committee meeting speaking about Medicaid program and how to tighten and make it efficient and cost related. Committtee added 28 million on a bill to the medicaid. 2:14:34 ~ 1/17/2012 10:50:55 AM ~ Nicholas: When we leave in March, have programs, funding, exceptions in next budget. Trying to land in positive in two years with variables you do not know how to anticipate. Example: employee saying enrollment going up 10% and provider saying need reimbursment rate to go up, May have to tell doctor rate will not go up but actually drop. Doctors will come to us. If that is the choice, make it. Burn rate. you make tough decisions, screaming providers come to us. If you are making political decisions so you do not have screaming providers and end up with deficiet at end of year we did not provide for. Meier's point. We make the political decision. You do not make it within agency. 2:17:50 ~ 1/17/2012 10:54:11 AM ~ Forsludn: yes, it makes sense. No issue making those decisions or talking to groups about the decision. I am telling you it is more than a challenge than you are making it out to be. I have no problem with message, 2:18:33 ~ 1/17/2012 10:54:54 AM ~ Meier: Look at numbers. 3.9% reduction in provider rates would get you 70 million. Less than 1% would get you the 20 million. If we decide you don't have the money needed for this program, change the rates, let them talk to us. 2:19:29 ~ 1/17/2012 10:55:50 AM ~ Forslund: Conceptually hear. Do not agree with across the board cuts, should target it, protect some areas. 2:19:59 ~ 1/17/2012 10:56:20 AM ~ Edmonds: Complicated, fee for services, correlation between decreasing rates, increasing services. Two of three factors you do not have control of. 2:20:25 ~ 1/17/2012 10:56:46 AM ~ Forslund: Much more complex. Examples: by cutting rates do you end up with more nursing homes at risk, providers that asy it is not worth it so harder to find physicians to take patients. Do not want to be where medicare patients only have a handful of place sto go, patients will got to emergency room which will drive up costs. 2:21:49 ~ 1/17/2012 10:58:10 AM ~ Peterson: Stats on providers not agreeing to medicare contracts, statewide. Trend of more providers, dentist, doctors, hate to punish providers,low rates and providers backing out. Fraud. Last year or two trend of provider's? 2:23:02 ~ 1/17/2012 10:59:23 AM ~ ForslundL I do not have numbers tracked over time. In last few years have not dropped rates. Across the board cuts, some providers are more at the edge. Some are able to take a cut easier than others. When they won't take the cuts, they will leave the program. Can get the data. Has not been reported to me that we have been losing providers over the last year or two. I saw it in Casper in the medicare area..signs not taking medicare patitents. Happens with declining reimbursement rate. Can give numbers. 2:24:50 ~ 1/17/2012 11:01:11 AM ~ Green: WE have not seen a reduction in providers, have seen providers taking fewer medicaid clients. 2:25:17 ~ 1/17/2012 11:01:38 AM ~ Peterson: Providers costs increasing on insurance, staff, medicine which is driving force. 2:25:45 ~ 1/17/2012 11:02:06 AM ~ Nicholas: Understand compexitiy. Can shift dollars. Ex: From primary care to emergency. If you budget 1.8 million, it will get consumed. When you look at 95/5 plan. The bottom 95% should not absorb the same cuts as the top 5%. How providers can derive rates are the complexitiy. if providers do not accept rates, drive it to the hospital, which is not a good plan. Open discussion with you and staff. Staff sends message and how they send it is important. We area t 1.7 billion for your entire department. Largest program, more than education and more than any agency in state except Highway. 2:28:45 ~ 1/17/2012 11:05:06 AM ~ Forslund: 13/14 budget: Absorb as much as possible, build budget in accordance with restructured budget, no new positons, in accordance with laws, do not bring forward requests to make up federal funds. 95+ programs, many federally financed. Did not want to set precedence. Address infrastructure issues at state faciilties. Exception requests: More denied than what you see. Surprised at exceptions that had to be put in the budget, required by statute. presented exceptions where no funding was appropriated int he past, talk about cleanin up those area. Exceptions to modify personnnel cost allocations. Many of positions federally funded, look at periodically to see how much work is for federal programs that can be reimbursed and what can not be. Identified a large number. 750,736 savings in budget. Grant allocations, new or extended grants. Be transpoarent> 2:32:12 ~ 1/17/2012 11:08:33 AM ~ Forslund: These are 50/50 funds. If the employee to doing 70% federal work, we need to get more money. If they are doing less, we don't want to have to make that money up later. 2:34:37 ~ 1/17/2012 11:10:58 AM ~ Meier: Is there some date in time like 2019 that we have to do something. 2:35:07 ~ 1/17/2012 11:11:28 AM ~ Forslund ACA sends down lots of regulation regardless of taking monies or not. 2:36:03 ~ 1/17/2012 11:12:24 AM ~ Berger: Explain it again 2:36:15 ~ 1/17/2012 11:12:36 AM ~ Forslund Page 11 The intent of the program Go to the next page 12, What does this program take in resources. # of presentations, those are activities. Next step is these activities Colorectal screening - how much is that costing us. Outcome - hard to measure but are we accomplishing what we set out to do. Some kind of tool to measure that output One we can evaluate, second we are doing a merisible job or three eliminate the program. That is what the problem is with across the board cuts This is not programmings This is a cultural change. We want to learn 2:42:50 ~ 1/17/2012 11:19:11 AM ~ Edmonds The proof is in this target number. How are you measuring success. 2:43:34 ~ 1/17/2012 11:19:55 AM ~ Forslund The program mgs. make those calls They come in and report their performance. How efficient are they? WE are going to do all these wonderful things for the next year. Same thing moving towards the end product. Focus on this. 2:46:10 ~ 1/17/2012 11:22:31 AM ~ Nicholas Why would we give you a 7% and then turn around a 8% decrease. If we send you out and You go met over the next year with the labor committee , you might with the committee but you decide who makes the cut and who doesn't. Is there a way for you to make quick decisions on certain programs and ax them? Give the gov a list of non-performing programs. If the exucitive committee 2:50:20 ~ 1/17/2012 11:26:41 AM ~ Forslund, What your describing is giving more ability to agencies to manager their programs. I would be suppportive of that. I talked to the Gov and told him that across the board cuts are not a good way to go. These are ones that we should circle the wagons and whcih ones we should leave out. 2:53:17 ~ 1/17/2012 11:29:38 AM ~ Nicholas Ok, just hold your programs the way they are. If we say your budget is flat and we want cuts Did I have to give you 51 mill. to cut 8%. 2:54:54 ~ 1/17/2012 11:31:15 AM ~ Forslund. I came in at a interesting time. We now have to increase I cut 49 mill. to stay the same. So there is a hand ful of items that drive this increase. We lost federal funding that we need to replace. Whatever amount you give us, that is what we will live with. 2:57:19 ~ 1/17/2012 11:33:40 AM ~ Meier There is a couple in the budget that are scared cows. I'm not sure if that will work with the labor committee. What went on with that. 2:58:38 ~ 1/17/2012 11:34:59 AM ~ Forslund: No Washington Monument proposals. Everyone of these programs has a consingency. 2:59:50 ~ 1/17/2012 11:36:11 AM ~ Nicholas I'm thinking out loud. Maybe we ought to identify what programs that could be eliminated. Are we going to have 2, 4, & 8% cuts. There are programs that we started recently. Lets identify the last 4 or 5 programs and see what they are 3:02:21 ~ 1/17/2012 11:38:42 AM ~ Berger Lets look at the next component Position changes 3:02:49 ~ 1/17/2012 11:39:10 AM ~ Peck A summary of all the position changes We put one summary for each division that has a division change. You have a list of every position that has a salary change. It's also in the exception request. The next schedule in your packet. This is desktops, monitors, etc The next summary is of the600 series It goes from the most expensive to the least Page 25 3:06:03 ~ 1/17/2012 11:42:24 AM ~ Nicholas What you don't have is medicaid costs. Major groupls 3:06:46 ~ 1/17/2012 11:43:07 AM ~ Peck That would include hospitals etc. Pudget item 470 further down 3:07:31 ~ 1/17/2012 11:43:52 AM ~ Nicholas That list would show us where the money goes 3:07:50 ~ 1/17/2012 11:44:11 AM ~ Forslund: The providers is the waivers 1 Hospitals 5 Pharmacies 3:08:48 ~ 1/17/2012 11:45:09 AM ~ Peck The data is similar 3:09:08 ~ 1/17/2012 11:45:29 AM ~ Berger 900 series 3:09:23 ~ 1/17/2012 11:45:44 AM ~ Peck $25,000 or more and the Vender The rest are under $25,000 but didn't think you woud be interested in that. Page 26 Innovative Resoucre Group APS has an office in Cheyenne UW Survey and valuations Goold Health Systems Namigant Consulting Can't be lower that the medicare payments Healthways Quitnet, LCC 3:13:48 ~ 1/17/2012 11:50:09 AM ~ Harshman Individuals those are big dollars 3:14:41 ~ 1/17/2012 11:51:02 AM ~ Nicholas Is this packet proved to the labor committee 3:15:19 ~ 1/17/2012 11:51:40 AM ~ Forslund The substance has been given to the labor committee 3:16:03 ~ 1/17/2012 11:52:24 AM ~ Berger Break for lunch and retrun at 12:45