Monday December 14, 2015 JAC Index121415am1 Agency004 Department of Health Director Tom Forslund 12/14/2015 8:59:26 AM Meeting called to order by Chairman Ross. Microphones are not working. Richards: Roll call. Quorum established Harshman: Information about the recording, taping. 12/14/2015 9:01:42 AM Director Forslund: Introduction of staff. Will give an overall view, discuss significant issues, then move into the 2017-18 budget request. 2015-2016 Budget: 1st issue: Estimated overrun with Title 25 costs related to involuntary hospitalization. 4.4M budgeted for biennium; anticipate spending 15.7 M, projected overrun of 11.3 M for the current biennium. 2nd: Governor stated there would be a shortfall for the current biennium Review showed 17 M stripped out of our budget for the current biennium. Ross: ? Forslund: Deseret Nursing home debacle, lost 360,000 as a result of that closure. 12/14/2015 9:06:53 AM Burn: If your expenses have exploded from Title 25, will you get the same story from the counties? Forslund: County pays the first 72 hours of incarceration. It falls to WDH after that. There is no cap on the number of times. Some county governments do not have to absorb those costs. EX: Natrona County does not, the medical center does. Burns: It will not be a general overall increase. It will be a spike in some coutie Forslund: yes Burkhart: Thanks for the way you handled Deseret situation. Hastert: Task force has recommendations. Forslund: I will be moving into those. Perkins: Explanation of 17M? Forslund: it is on top of it 12/14/2015 9:10:34 AM Forslund: How the WDH absorbs these hits. Title 25 overruns handled by drawing down fund 409 at the hospital, which is 100% of the reserves, using 1.5M in 100 series flex, payment reform for nursing homes last year so Wyoming Life Resource Center received additional revenue which we tapped, expect to have some significant Medicaid savings this biennium Medicaid savings: Woodwork population discussed last week. ACA going into effect caused additional money to be appropriated. The enrollment for woodwork and children population is lower than projected and the rate is slower. The implementation of the new WES system (Wyoming Eligibility System) has helped to reduce the enrollment of ineligible people. Perkins: System has helped identify people who weren’t eligible to be on Medicaid and they were removed? Forslund: Correct. IT need discussed in the past, expected savings. Technology allows us to do the reviews and they are updated quicker and are more accurate. Perkins: Amount saved due to WES? Forslund: Not at this time, estimate millions. Ross: Life Resource Center amount received? Forslund: We have not started pulling it out yet. Ross: Medicaid? Forslund: Moving on a monthly basis. We started with the state hospital then will move to life resource center. Stubson: Primary factor for the WES system? Forslund: Income primarily. Must be low income and part of a designated group. 12/14/2015 9:17:41 AM Forslund: 17 M out of budget for this biennium - Medicaid, mental health and abuse and public health. Many of these are one time savings. Harshman: 6 M in fund 609, Forslund: fund 409. Harshman: What is that fund? Forslund: A fund that revenue goes into for property rental, payments from life resource center. We can use it for a limited number of things that you said we could use it for. Connolly: Any other place where individuals are being involuntarily committed under Title 25? Forslund: 1st: Primarily at the state hospital, 2nd is at designated hospitals, privately run, have physiatric care. . EX: WBI in Casper Connolly: How many? Forslund: 4 or 5. WBI is the large one. Forslund: 2015-16: DD Waiting list reduced to 195, will reduce further next month. Wait should not be longer than 18 months. That was the target. Additional appropriation and waiver reform have helped us to do that. 12/14/2015 9:23:16 AM Forslund: 2017-18 Budget Medicaid Expansion, Title 25, health facilities, Wyoming resource staffing Medicaid Expansion: Governor asked me to prepare two budgets, one with Medicaid expansion, one without. Governor elected to include the expansion in the budget presented. Since then, numerous changes in WDH have complicated. Handout 048-047 and handout 048-056. MMIS Replacement Project- Federal govt pays x % of these systems. We pay the rest. Title 25. WSH and WLRC Equipment, Computer Replacement – biennial requests. Dept of labor rule change. Medicaid Waiver Rate Rebasing. If we have rebasing than we do not need the dept of labor rule funding. Trauma Unit Site Reviews, Medicaid Waiver Rat Rebasing is for DD and it is a statutory requirement as is preschool enrollment Growth as is preschool external cost adjustment. Last is Health Information exchange system. Total of 237M GF new spending. Almost Half of it is Title 25. 12/14/2015 9:30:31 AM Forslund: Optional Adult Medicaid Administration is a 50-50 match with the federal government. Optional Adult Medicaid Expansion 10 M state funds, 263M Federal funds. Everything below that is a repurposing of funds already in the budget. They would be moved out of that particular program and into the match required for the Medicaid expansion. Stubson: I would have expected that the 5M would be in there but covered by savings. With the new Medicaid expansion, would we need the 5M Forslund: it would be self funded within the Medicaid budget. We would still have to come up with the match but would not ask for the new GF appropriation. Stubson: So it would be federal funds? Forslund: It would be under all those down below in red, out of that allocation and the reduction. We would move the 5M to make the match requirement. We struggled on how to show the committee that if we did the expansion, the GF match for the MMIS could be self-funded. Stubson: It seems like the $5M should still be because it will be spent. Harshman: Same for Title 25 funding and compute replacement. I think we see what you are doing, doesn’t show it as clearly. Forslund: These are exception requests so we are not asking for the additional money. It does not go away but I am not asking for additional money. Perkins: page 3 budget exception with expansion, program reductions the total of the first three is roughly 5M. Are you saying that is the offset for the one time request for MMIS? Forslund: Prescription drug assistance program reduction of 950,000. The GF contribution is reduced by that amount. Perkins: MMIS project would not have to have the $5 M appropriation request because of savings within the budget. Offsets ? Forslund: Correct Ross: How are you saving the money? Forslund: Over the years, the legislature has established and funded programs to help lower income with their health care funding. Under the expansion, the individual can now sign up for Medicaid which would pay for that service and would no longer be paid for 100% state GF. Outside of facilities we don’t have that many employees. Paid for by Medicaid funds with an enhanced match. Fed. Govt pay 90% so we do not need the 90% that came from the state funds so grab that money, take it over to the Medicaid side to make the match. Burns: How many people are in the Medicaid program? Forslund: 75000 Burns: How many new members with the expansion? Forslund: 20,000 Burns: What happens if it is more than that, like 40,000? Forslund: Some states at higher than expected enrollments. We looked at characteristics of other states and our experience with the woodwork population, we think we will be closer to our projection. We built in a cushion of 13% in our projections. Burns: Based on an additional x number of people? Burns: Some states are receiving 75% reimbursement from federal govt for Medicaid. We would receive 50%? Forslund: Yes as long as they are low income and part of a category. Burns: ? Forslund: Allows people between 19 and 64 who are low income but do not fit one the categorical groups to be covered. Currently, they have to go to the ER or to a facility with free care. People from 0% to 138% who do not meet category may come on the Medicaid rolls at the enhanced rate of 90% payment from the fed govt. Burns: What percentage below? Discussion between Burns and Forslund of the numbers . Forslund: Current model, the payment rate is 50/50 federal/state. Burns: The additional 20000 come in at 90/10 rate. Forslund: Yes Burns: Congress point of view of difference in reimbursement rate. How long will that last before the Federal Government whittles the rates down. Demographic bomb for future Wyoming legislatures. Forslund: With traditional Medicaid, the %s vary by state. The expansion program is the same for all 50 states. If Congress were to change the program, all 50 states impacted. Build into the legislation that if the fed govt. drops below the 90% rate, the program would automatically go away. People having health care in the short term are better off than relying on ER care. There is no guarantee on the reimbursement rate by the federal government. Wasserburger: If the State of Wyoming enters into expansion, we can terminate it at any time? Forslund: yes. We have been told it is a voluntary program as is the traditional Medicaid program. We came into it in 1967. No state has left the traditional Medicaid program at this time. Expansion program clarified as voluntary. If you come back into it later, there will not be a retro on the matching funds. We are into the 2nd year. The first three years are a 100% match. Perkins: The two years we did not join, how much did we appropriate? Forslund: We have foregone 63M, match first two years would have been zero for the state, except for administration, then ratchets down until it hits 90%. Connolly: Has any sate left the expanded Medicaid? Forslund: No Stubson: Confidence in your numbers. Siting a 2012 study. Update to the study? Forslund: Millimum was the original study. Our dept. has reviewed it and upped it by 13%. Stubson: Discussion of people with private coverage who will leave it and go to Medicaid. Any study on that? Forslund: The 17,000 included that. We considered the underemployed, unemployed and the employed. They are projections. I am more comfortable looking at our experience to date. Harshman: ND was the only one that was accurate. All others enrollment exceeded projections. Forslund: Minnesota was also. Harshman: Why did everyone else miss the mark so wildly and those two states did not? Forslund: Looking at health care systems, Wyoming is an outlier. Harshman: Why do you think ND and Minnesota were so accurate? Forslund: Many states used the same consultant. We reached out to CRMS and asked for their perspective. 12/14/2015 10:02:10 AM Stretch: Introduction of Senator Bonner. 12/14/2015 10:10:53 AM Meeting called back to order. Forslund: ACA – 31 states have expanded so fare. Match rates are done each year by calendar year. ˝ year at full, 1 yr. at 95% and ˝ year at 94%. In conclusion to the Medicaid expansion, I would ask the committee to look at exception requests in the alternate budget if you do not accept the Medicaid expansion. That will not work. I will be back in with significant requests next year if they are not funded this year. Hastert: Title 25 funding. Current budget has a significant shortfall. $4.4 M budgeted and will spend roughly 16M. Ross: 11 or 12 M shortfall for Title 25 funding. Hastert: If we had expanded Medicaid, we would not have had that shortfall or it would have been reduced. Forslund: Medicaid expansion. Burns: If we go with expansion, title 25 would go under Medicaid. Some already under there. Forslund: There are some. By being able to repurpose funds already in the system, more flexibility. Burns: Is there any impediment to those already Medicaid recipients who become Title 25. Is there anything stopping Medicaid paying for it now. Forslund: Medicaid cannot pay incarceration costs (state hospital). That is part of federal legislation for mental health reform. Burns: would expansion change that Forslund: Medicaid Burns: How does expansion help our Title 25? Forslund: Can you keep people out of crisis in the first place? Burns: 75000 current Medicaid recipients, expansion adds 20,000. I am trying to figure out how expansion helps alleviate Title 25 problem? Forslund: Is Title 25 problem, just the spending? Wasserburger: If Wyoming enters expansion and federal govt .changes the 90/10 to 60/40 and we decide to no longer participate. Is it true that once the people enter Medicaid, they are always covered? Forslund: No they would run out their time period that year and then would not receive the benefit. Burns: Is that true for all Medicaid recipients? Forslund: We can end waivers but not programs. Burns: contradiction Forslund: Traditional Medicaid vs. expansion. Connolly: Relationship of Medicaid expansion to Title 25. 62% of current Medicaid recipients are children so talking about Medicaid expansion are a different population..adults. page 3 of handout. The expectation is that people of Medicaid not eligible for will take advantage of services and will decrease need for ER visits and involuntary commitments. Example given. We are providing block grants to community mental health organizations. Moniz: What is the breakeven number? (New enrollments) Forslund: All projections are based on 20,000 individuals. If it was 40,000 the state match would have to go up to meet the expenses. The expenses depend on the services used. Look at GF number and double it. Hastert: People without insurance who are in the gap. People who go to the ER are a higher drain on the medical system. Am I characterizing the group> Forslund: It does not matter how much money they earn, they are not eligible because they do not meet one of the criteria. People at 100 to 400% of poverty level can go onto the federal exchange and get a subsidy. If you are below 100% cannot go to federal exchange. You are to get coverage through Medicaid. That was the design. The Supreme Court said it was up to states whether to expand. Those people are in the gap. The people between zero and 100% must get care through ER or free care. 100 and 138% today can get a subsidy. If we expand Medicaid, those people in the 100-138% can go off the exchange and onto Medicaid. Burns: What about children? Forslund: This has nothing to do with children. People aged 19-64. Harshman: Childless adults is the group Forslund: Essentially. Stubson: do we know how many of those in that population have taken advantage of the exchange? Forslund: Guess 2800-3000. About 56% of this population are employed. The majority are working but have not coverage. (Of the whole population of 20000) 12/14/2015 10:38:12 AM Title 25: Cost exploding – page 5 of handout 048-056. Amount being paid out monthly. Patient costs at designated hospitals as part of Title 25. Task Force. There are many players in the Title 25 system. We are not in charge of it. We write the check. Law enforcement, DOC, Attorneys , County Commissioners…. Page 6 shows expenditures and trending. Page 7 shows budget vs. cost. Page 8 background of state hospital. Color coded for number of days patient has been at the hospital. Red is people at designated hospitals. Brown is greater than 365 days. That is a major problem. It is turning into a facility where people are staying longer than they should be. The state hospital should be for people in crisis. Ex: Elderly with psychiatric problems, violent patients, disabled patients difficult to find facility. We can’t get a Title 25 patient into a filled up State hospital bed. Page 9 shows more people are going into the system. We as the WDH have no control over people being infused into the system. Page 10 shows by county where it is occurring. Look at purple for 2015, jumps in that number. Harshman: It looks like 3 counties, Fremont, Natrona, Sweetwater. What has changed in those three counties. I think a player has changed their policies. Ross: Natrona has referrals to WBI from other counties. We don’t know what is driving Sweetwater. Harshman: Information Forslund: We do not have a centralized data collection. We are trying to gather information. It is voluntary for counties to give the information. Harshman: I know you have a bill from the task force members. We don’t have the information Ross: Agreed Wasserburger: Gatekeepers discussion. Forslund: In WDH opinion, the system needs revamping. Community mental health centers can be of assistance. Before a person is infused into Title 24, the community mental health center can do an assessment and financially incentivize Gatekeepers. We give block grants and do not prioritize. We need to prioritize the population and reward for dealing with people who are higher needs. We drafted a rough bill, not moved forward. Wasserburger: Can Medicaid expansion dollars b used for Gatekeeping. Forsland: Medicaid funds can supplant a portion of GF dollars going tint mental health system 12/14/2015 10:51:39 AM Forslund: page 11 Increasing. If projections hold it may be 213.2 M. Page 12 – discharges. We have a problem trying to release patients from the state hospital, once they meet medical necessity. They need to go somewhere. Some are homeless or have lost their home. We need stepdown services. We can’t find a place for them. Many of the clients do not have insurance so no place to get medication. Lack of jobs. We end up keeping clients longer than normal or that we should. Stubson: How much control do we have over designated hospitals and whether they throw them out the door? I have heard antidotal stories. Recycling of patients. Does WDH have control? Forslund: We don’t know about many of the patients until we receive a bill for them. The information I have is antidotal. We have hired a 3rd party to do reviews “utilization reviews” of the state hospital and the designated hospitals. Do the patients meet requirements and what happens to them after they are released? Incentivize the community centers to do care coordination. 12/14/2015 10:58:25 AM Forslund: red bullet number 3. Page 13 and 14. I would like to establish an 8 bed group home at Evanston, at the State Hospital. Voluntary basis. Patients at State hospital who do not need intensive treatment. I need 12 positions. Move from Wyoming Life Resource Center vacant positions. $785 per day plus medical costs for clients is the cost at designated hospitals. Burns: What would be the nature of these 12 people? Forslund: The staff are the 12 Burns: The people that would move. Forslund: 8 beds. Patients would receive post-treatment support to integrate back into the community Burns: People there more than 365 days? Forslund: No. It would be 185 days and below or those ready to be released. They have been stabilized but not ready to be kicked out of the van. Need stepdown services. Burns: Avg length of stay at group home? Forslund: 90 days. I am no asking for an appropriation. I am just asking to move positions. Greear: Out of incarceration phase, Medicaid could pay for the treatment? Forslund: Correct Harshman: If 11M is the continual uptick, we talked about building another wing. Is Evanston the only facility you could accomplish this at? Task force members, is that part of the capital request going forward. Forslund: Absolutely. State Hospital is designed to be short term crisis stay. Tough clientele that private sector is unwilling or unable to treat. Task force – get State Hospital back to its core mission. Best scenario is to make the Wyoming retirement center change its purpose and mission, make it a long term and intermediate facility. Perkins: You referred to Wyoming Retirement Center. I think you meant the WLRC. Forslund: Wyoming Life Resource Center. We need help with the facilities. Slide 9 – upward trajectory must be addressed by mental health reform. Also address through facilities. Can we stem the numbers going in? Nicholas: Outpatient care facility is already there? Forslund: correct Nicholas: Start up costs and how soon to get started? What is the daily rate for home? Forslund: We have developed that. Issue will to be able to hire people and how quickly. The biennium expenses for this would be 1.4M+. The facility startup costs were negligible. Opening date 60 days from date of approval to fill positions. Nicholas: What do you need from us? Forslund: I believe I have the authority to transfer positions. I wanted the conversation with you. I would have to go through the internal process. All positions are frozen, need to go through governor’s office to unfreeze. 1.4M cost for biennium . One person has a $287,000 per year cost at designated hospital, just room and board. Savings of 1 to 1.5 M. it makes good economic sense. Burkhart: 12 vacant positions at WLRC. How long have they been vacant? Forslund: Severance payments offered at WLRC. Legislature agreed but said if you used severance, position must go away permanently. Task force work shows we need a new group of employees at WLRC when we move into its new mission. We put a hold on the positons. Vacant from a few weeks to a few years. We are only filling those we consider critical. Burkhart: Group home won’t be necessary after WLRC mission has been implemented. Reversion of employee positons. Forslund: Possible ... Title 25 group is morphing into looking at the whole system. 12/14/2015 11:19:05 AM Short break 12/14/2015 11:28:53 AM Forslund: Tobacco Settlement Funds. Revenue was not going to meet expenditures. $30M received. Reduced spending requested by Governor. $7.4M reduction to department. Drug Court supervised treatment, health care professional loan repayment program and telehealth program affected the most. Nicholas: Can prioritize those programs least affected or useful prior to markup? Forslund: Health Facilities task force, Level I and II studies on health department facilities. Vet Home not included. $155M for state hospital and life resource center renovation. Life Resource Center, not use savings for severance payments, holding 12 positions open thru attrition. Study for medical education mentioned during UW JAC hearing, report done internally, and do not necessarily need appropriation. 12/14/2015 11:56:45 AM Lunch Break