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2005 Testimony

Testimony Before the House Appropriations

Human Resources Subcommittee
Representative Delzer, Chairman

HB 1012 - DHS Budget - Medical Services Budget Area

January 12, 2005

Chairman Delzer, members of the committee. I am David Zentner, Director of Medical Services for the Department of Human Services. I appear before you to provide an overview of the programs administered by my Division with the exception of long-term care.


The Medical Services Division administers three programs, they are Medicaid, the State Children's Health Insurance Program (Healthy Steps), and Children's Special Health Services (CSHS). This area of the budget provides public health care coverage for families and children, pregnant women, the elderly, and disabled citizens of our state.

Medicaid is by far the largest portion of the budget. As of November 30, 2004, a total of 52,300 individuals were enrolled in the program. Attachment A shows the number of enrolled Medicaid recipients in November by category, and Attachment B shows the number of enrolled recipients and the number of recipients for whom a payment was made since the start of the current biennium. Attachment C details the number of children enrolled in Healthy Steps since the beginning of the current biennium. In addition, about 300 children had health care services paid on their behalf through CSHS during the year ending June 30, 2004. An additional 1,039 children received assistance through specialty clinics and information and referral services.

Program Trends

The overall economy in North Dakota has seen a marked improvement over the last several years. The Federal Medical Assistance Percentage (FMAP) is calculated based on per capita income over a three-year period. As a result, the FMAP for North Dakota has dropped considerably over the past two years, and it is anticipated that it will continue to fall through at least 2007. The current FMAP is 67.49%. The percentage will drop to 65.85% for the 2006 federal fiscal year beginning on October 1, 2005. It is anticipated that it will further decline to about 63.23% for the 2007 federal fiscal year that begins on October 1, 2006. The impact to the Department's budget as a result of this FMAP reduction totals about $32 million of which about $11.0 million is directly related to services covered in my testimony today.

Health care becomes an ever-evolving process that produces new prescription drugs, new diagnostic tools, and new sophisticated treatments and surgical procedures. While these changes often result in dramatic breakthroughs in treatment, they are in many instances expensive and therefore increase the overall cost of delivering services throughout the health care system. This trend will likely continue into the foreseeable future.

While the number of individuals eligible for the programs administered by Medical Services has leveled off, we note that many have chronic conditions that require extensive treatment. We see this trend continuing, and we are interested in instituting disease management to improve the health outcomes of those individuals who have high medical costs, while at the same time trying to reduce overall costs to the program over time.

Medicaid is the single largest payer of mental health services in the nation. Many individuals with severe mental conditions rely on Medicaid for services. For example, of the top 20 highest cost drugs paid through the Medicaid Program, 13 are related to mental illness conditions. We are the primary payer for individuals who are severely mentally ill. Across the nation about 50% of the costs related to these diagnoses are paid by Medicaid, and this trend is expected to continue into the foreseeable future. It behooves us to continue to improve the efficiency and effectiveness of delivery of services to this population.

We have seen a steady decline in our ability to serve our customers because of our current payment system. The current Medicaid Management Information System became operational in 1978. While it has served us well in the past it is imperative that we develop a new system during the next biennium. Without a new system we will continue to struggle to ensure prompt and accurate payment of claims, struggle to institute changes that will improve our ability to monitor the delivery of services, and struggle to evaluate information to ensure the overall integrity of the Medicaid program. You were presented a more detailed explanation of that need during the Department's overview testimony last week.

Performance Measures

While we have experienced some delays in processing claims, staff has still been able to process the vast majority of claims within 30 days of receipt in our office. Most pharmacy claims are processed within a week because of the point of sale process used to pay these claims. The charts below indicate our progress to meet our goal of processing 90% of our claims within 30 days, and 99% of our claims within 90 days of arrival in our office. We have made great strides in reducing the backlog, and as of November 2004, 94% of claims have been processed within 30 days.

Performance Measures 1  Performance Measures 2

CY 2004 through September 2004

In addition it is imperative that claims are processed in an accurate manner. The North Dakota Medicaid program participated in a pilot project with the federal government to determine the accuracy of claims processed during 2002 and 2003. The results of that pilot program, based on a scientific sample of claims, revealed that our accuracy rate was high.

Performance Measures 3

Another major goal is to ensure that our children receive appropriate preventive and treatment services. Our Health Tracks screening program for children through age 21 is designed to detect problems early, and provide treatment before their conditions deteriorate and become more expensive to treat. The following chart details the results of our efforts to improve the number of children who are screened through this program.

Performance Measures 4

Budget Changes

The following information provides detail and comparison of the current biennium appropriated funds with the amount requested for the new biennium.

  2003-2005 Budget 2005-2007 Request Increase / (Decrease)
Salaries 5,216,578 5,799,772 583,194
Operating 4,685,177 4,821,231 136,054
MA Grants 372,882,755 393,985,188 21,102,433
Total 382,784,510 404,606,191 21,821,681
General 90,706,244 108,344,787 17,638,543
Federal 269,783,775 270,338,401 554,626
Other 22,294,491 25,923,003 3,628,512
FTE 59.0 61.0 2.0

The grant line item for Medicaid and the Healthy Steps programs total $391.2 million, of which $103.9 are general funds, and $25.4 million are other funds. It includes $1.3 million, of which $.4 million is state funds to allow individuals to set aside an additional $2,500 for funeral expenses. Also included in the grants line item is $1.7 million, of which about $.4 million is retained funds for nursing facility surveys, and nurse aide registry, and $1.1 million, of which about $.4 million is state funds for Children's Special Health Services programs.

This budget does not include any Intergovernmental Transfer (IGT) funding because this program was phased out as of July 2004, in accordance with federal regulations. The current biennium appropriation for the Medicaid and Healthy Steps programs totals $370.0 million of which $27.5 million is IGT pool payments. For comparison purposes, if IGT pool payments are factored out of the current biennium the totals for the current biennium are $342.5 million of which $77.9 million are general funds and $21.6 million are other funds. When IGT pool payments are excluded, the requested increase totals $48.6 million in total funds and an increase of $26.1 million in general funds. Attachment D details the current appropriation, the anticipated expenditures for the current biennium, and the requested funding for the next biennium for each service.

Budget Highlights

  • Due to the improving economy, the FMAP will be decreasing each federal fiscal year as noted in my comments above. This will result in the need for an additional $11.0 million just to maintain the program in its current form because of the drop in federal financial participation.
  • This request includes provider inflationary increases of 2 percent per year for most services. The cost for this increase totals $6.9 million of which $2.4 million is state funds.
  • Inpatient hospital services have trended much higher than anticipated at the beginning of the current biennium. This was caused primarily by an increase in the number of hospital admissions. We are requesting $80.0 million of which $28.1 million are state funds. This compares to $63.4 million of which $19.3 million are general funds in the current biennium.
  • Physician services have also increased dramatically primarily due to an increase in the number of services provided by this group of providers. The actual units of service for the first year of the biennium were 27.2% greater than what was included in the current appropriation. We are requesting $55.4 million of which $19.4 million are state funds. This compares to $49.3 million of which $15.4 million are general funds in the current biennium.
  • The prescription drug program is based on the assumption that the prior authorization program will continue to evolve, and that the other cost savings initiatives will remain in affect during the next two years. We are requesting, after drug rebates have been factored in, a total of $107.9 million of which $24.3 million are general funds and $14.1 million are retained funds. This compares to a current appropriation of $96.1 million, of which $16.2 million are general funds and $13.9 million are retained funds. Drug costs that are passed on to pharmacists by the drug manufacturers are generally higher than general medical inflation. In addition, new drugs that come onto the market often have high prices. For this reason, the inflation factor for drugs was estimated at 13.8 percent per year.
  • We are requesting $10 million of which $2.5 million is state funds for the Healthy Steps program based on payment of 2,300 premiums per month. This amount includes a premium increase of 17.9% requested by Noridian Mutual Health Insurance Company. As of December 1, 2004, a total of 2,318 children were enrolled in the program.
  • The request for administrative funding remains relatively unchanged. Operating expenses total $4.8 million, an increase of about $136,000 or a percentage increase of only 2.9%. The bulk of operating funds of $4.4 million or 92.5% will be used to pay for contracted services that include medical consultants, drug pricing, utilization, prior authorization, hospital utilization review, hospital audits, and inflation indicator information. The majority of increased costs are related to inflationary increases for these contracts.
  • The salary and fringe benefit package includes 61 employees. These employees process 2.4 million claims per year, determine eligibility for the Healthy Steps Program, answer hundreds of calls per day from providers and other interested parties, develop and implement program policies for the three programs, conduct utilization review activities, establish payment and rate setting policies, provide screening services for children throughout North Dakota, oversee specialty clinics for children with special health care needs, distribute specialty food products for certain individuals with rare metabolic diseases, and many other tasks related to ensuring that we provide quality services to the clients, providers, and others that we serve.
  • This request includes two new employees for the Medical Services Division. One position is a pharmacist assistant that will help ensure that we collect the appropriate amount of drug rebates, assist in reviewing claims for accuracy and responding to written and verbal requests from providers, assist with the prior authorization process and help in monitoring the overall pharmacy program. The second position is an eligibility technician that will assist in the determining of eligibility for the Healthy Steps Program. At present one staff person determines eligibility for all Healthy Steps children. With the incorporation of Healthy Steps into the Vision system we anticipate additional workload to establish eligibility for this program. Eligibility for Healthy Steps is determined on a prospective basis and the additional staff person will ensure that new applications and renewals are processed before the end of each month in order to ensure that children do not lose health care coverage. In addition, the additional staff person will permit the Department to be better able to respond to requests for information from families and others who are interested in the program.

I would be happy to respond to any questions you may have.



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