The captain of this rowboat will no longer have to check his speed if Senate Bill 27 is passed.

The proposals include eliminating the state motor vehicle registration surcharge, repealing boating speed limits on Lake Winnipesaukee, and establishing a managed care platform for the state’s Medicaid program.

Kill the Surcharge

Senate Bill 78 – A motor vehicle registration surcharge enacted in 2009 as a two-year temporary funding measure could die sooner.

Sponsored by Sen. Andy Sanborn (R-Henniker), SB 78 would immediately repeal a 2009 provision that raised registration fees and surcharges for certain vehicles — from $35 to $75 depending on the size of vehicle. The resulting revenue is designated for “highway and bridge betterment.” Sanborn’s proposal would reinstall the previous fee structure and eliminate the surcharges, which are due to expire June 30.

The bill’s fiscal note says revenues for the Department of Transportation would decrease by about $6.59 million. That reduction would decrease state highway fund expenditures and local revenue an estimated $791,000 for fiscal year 2012.

Senate Bill 78 passed in the Senate Ways and Means Committee by a 6-0 vote with an “Ought to Pass” recommendation to the full Senate.

Lake Speed

Senate Bill 27 – Two years ago, lawmakers enacted a speed limit on Lake Winnipesaukee: 45 mph during the daytime and 30 mph at night. Now, a proposal sponsored by Sen. Lou D’Allensandro (D-Manchester) would replace that with no speed limit at all.

D’Allesandro’s bill would instead require boaters on any body of water to “proceed at a safe speed that is reasonable and prudent under the existing conditions,” with conditions like visibility, weather, and radar use to be considered in determining a safe speed.

The bill’s supporters say common sense boating shouldn’t be replaced by limits of personal freedom, while opponents say safety has been enhanced and the lake is more family-friendly with the current speed limit in place.

The bill was reported out of the Senate Transportation Committee with an “Ought to Pass” recommendation by a slim 3-2 vote.

Managed Shift

Senate Bill 147 – Sponsored by Sen. Jeb Bradley (R-Wolfeboro), SB 147 would set up a five-year contract with private vendors to manage the state’s Medicaid program.

Supporters say the long-term savings with a managed care program could amount to tens of millions of dollars not spent in administrative costs. In the bill’s fiscal note, the Department of Health and Human Services said it was difficult to determine what costs could be saved at this time. The Department provided the following information:

• In 2009, a leading health care actuarial firm, Milliman, Inc., reviewed NH Medicaid claims and conducted actuarial analysis to determine the viability of Medicaid managed care in NH. Their report identified factors that impact the ability of the state to achieve savings utilizing managed care. The existing reimbursement rates, size of the Medicaid caseload, administrative costs, and wrap-around responsibility were factors.
• New Hampshire’s reimbursement rates and administrative costs are comparatively low.
• The federal law requiring states to offer choice to recipients would require at least two managed care organizations to serve Medicaid enrollees.
• States must provide wrap around services; all services required by federal law including services which may not be included in the managed care benefit package.
• The Department issued a Request for Information in July, 2010 to solicit ideas from the managed care industry. Twelve entities responded and none of the responses offered savings. Most of the respondents stated they would need 6 to 9 months from the date of contract approval to program start up. Therefore the Department assumed there could be no fiscal impact until FY 2013.
• The New Hampshire Medicaid program currently utilizes most of the tools used in managed care including prior authorization, care management, and pharmacy benefit management.
• Based on the experience of other states, an up front investment is necessary as two claims adjudication systems are needed for the first 6 months after the transition date. The old MMIS system would continue to operate for 6 months since providers have 6-12 months to submit claims for services provided and new the claims would be processed through the new managed care system.
• Federal approvals required at various points in the procurement process may increase the timeline for implementation.

Senate Bill 147 unanimously passed Senate Finance Committee with an “Ought to Pass” recommendation.

>> Wednesday, March 23, full Senate session beginning 10 a.m. at the State House.

This Daily Dispatch was written by Michael McCord.

Unused, costly and life-saving medicines are now routinely thrown away, even when the state has paid for them. (photo by Hilary Niles)

Unused prescription drugs could soon be donated to some uninsured or underinsured patients in New Hampshire.

The Board of Pharmacy is working with three test sites in Hanover, Rochester and Exeter to roll out the Unused Prescription Drug Program created by the Legislature in 2006.

Under the program, some prescriptions that normally would get thrown away—due to a patient’s recovery, allergy or death, for example—could instead be re-dispensed to people who can’t afford them. This matters most to program advocates as a social cause, especially as insurance and health care costs increase and more people laid off are losing benefits.

The bonus is that it could also save the state money down the road.

“It has huge ramifications,” says Rep. Judy Day (D-North Hampton). She sponsored amendments to the program this year with House Bill 1184. It passed the House on Feb. 17, and it may help end the four-year delay in putting the original law to use.

the hold-up

Mostly for safety and liability reasons, the donated prescriptions have to be handled differently than prescriptions made fresh. From acceptable expiration dates and re-labeling to physical storage and database management, a host of details have bogged down progress.

House Bill 1184 allows for temporary storage, and clarifies that the system is voluntary and patients must know they are getting re-dispensed drugs. Immunity for pharmaceutical companies in the case of mishandling had already been provided, and HB 1184 extends that to the pharmacists who will do the re-dispensing, provided all rules are followed.

Rule-making authority for the program lies with the Board of Pharmacy. But as Day explains, they’ve faced a chicken-egg dilemma. “They couldn’t figure out the rules without knowing the programs the rules would be written for,” she says.

Enter the test sites, which actually more chose themselves than got chosen for the pilot. Representatives from Rochester Manor and SeaCare Health Services both brought the idea of an unused prescription drug program to the Board of Pharmacy, only to find out that it had already been created, but not yet implemented. They started working with the Board to help create the rules, and Dartmouth-Hitchcock also joined.

chain of control

The program depends on a strict “chain of control,” meaning no drugs that have been in the hands of patients are eligible for donation. Only doses dispensed individually by a professional can be used. This is why the three test sites are significant: They each have a different chain of control.

Chain of control can be simple, but it must be strictly documented. (photo by Hilary Niles)

Dartmouth-Hitchcock has its own pharmacy, but it’s not a retail site open to the public. Rochester Manor is a skilled care center with a consultant pharmacist, but without its own pharmacy. SeaCare Health Services in Rockingham County screens and refers uninsured patients through a pro bono physician network. It has no pharmacy, and it’s an open network rather than a closed system.

Each place dispenses medicine differently, so each will have to develop its own procedures for chain of control. Once operational, the sites will be models for more facilities like them to follow. But, depending on the site, the procedures could take anywhere from a few weeks to more than a year to put in place.

patience

“I’m leaving for Florida for a week on Monday,” says Rochester Manor consultant pharmacist Gene Johnson, “and I want to start this when I get back.”

Johnson is both a pharmacist and a lawyer—a background that likely helped him prompt the Board of Pharmacy to action. Johnson drafted his own procedures for Rochester Manor, and Day says his proposal gave a focus to the Board, around which it could start creating rules.

Gretchen Colpritt and Gene Johnson of Rochester Manor in Johnson's office, which will double as temporary storage for unused prescriptions. (photo by Hilary Niles)

His gumption also helped. “If people can benefit from something, why wait for the bureaucracy,” asks Johnson. “If you can identify a problem now, let’s fix it now.” He is clear that efficiency, more than patience, is his strong suit.

The Board of Pharmacy did not return calls or emails by press time to confirm that Rochester Manor is indeed empowered to move forward according to current rules, but Johnson is not expecting to wait.

It will be a different story at SeaCare. Given their decentralized operation, executive director Kathy Crompton expects it could take up to a year to finalize procedures.

But with the Board of Pharmacy’s recent progress, she has more clarity with which to return to the task. Since SeaCare serves the public in 21 towns, it has a much broader reach, and she is motivated to achieve it.

Dartmouth-Hitchcock could not be reached for an update on that facility’s progress.

potential

All involved are optimistic about the pilot, and see even more potential for the program. It could include controlled substances, and it could also be used in the state prison system.

Day says that’s where the state could really save money. Inmates lose Medicaid upon incarceration, she says, but the state is not allowed to deny heath care, so it must pick up the bill.

In the meantime, she’s thrilled with the current progress. She found that of the 30 or more other states that have created similar programs, very few have implemented them.

“I’m not saying it’s not hard to do,” she says, but she still expects it to get done.

A Committee of Conference has pieced together a compromise $3.2 billion general fund plan for the next two years, starting July 1.  These select members of the House and Senate reached the required unanimous approval for their report, but nothing guarantees their colleagues will go along with it. The full House and Senate are scheduled to vote on the budget—and dozens of other Committee of Conference reports—on Wednesday, June 24.

Meanwhile, a new lawsuit filed on the final day of budget negotiations seeks an injunction that would keep the Legislature’s hands off a critical $110 million it has claimed.  Gov. John Lynch and legislators plan to tap surplus funds from the NH Medical Malpractice Joint Underwriting Association. But over 200 JUA policyholders (healthcare providers and facilities) say the insurance money is rightfully theirs.

If the Belknap County Superior Court were to grant the injunction before the budget passes, the lost funding would send budget writers back to the drawing board.  That’s also where they could end up if either the House or Senate vote down the Committee of Conference report next week.

Shaping Up

More contentious than how to spend money in this debate has been how to raise it.  The Senate’s casino-style video slot machines were shot down by the House, which in turn lost its bet on the “gas tax,” and new levies on capital gains and estates.  A new tax on refinanced mortgages was also killed late in the game, and proposed suspension of the Business Enterprise Tax credit was defeated.  The NH Business and Industry Association claims a notch on its scorecard for the latter.

But the BIA is still licking a wound from a “mystery” amendment that it says amounts to double taxation.  This development, which was not revealed to the public in advance, passed the committee easily and is expected to bring in at least $15 million in new taxes from the state’s Limited Liability Companies.  According to Dept. of Revenue Administration Commissioner Kevin Clougherty, it merely closes a loophole that lets LLC owners off the hook for a 5 percent interest and dividends tax paid by other businesses.

Major spending cuts also helped close the $190 million budget shortfall. Some of what fell was a surprise to the NH Hospital Association.  Funding was lowered for medical education, which, coupled with the resulting loss of matching federal funds, will result in a $5.4 million hit for four teaching hospitals.  Another $6 million came from limiting Medicaid caseload growth to 1 percent.

More cuts will come from state employees.  The Legislature is not empowered to issue furloughs on its own, so Gov. Lynch will have to do that work, instead.  In addition to the 200 layoffs already approved, Lynch is now directed to negotiate layoffs and/or furloughs totaling $25 million with the State Employees Association and other unions.

The state will also scale back its contributions to municipal employee retirement accounts, from 35 to 25 percent in two years.  Those workers won’t lose money, but the contribution responsibility will shift to towns.

The Rooms and Meals Tax has also been bumped up from 8 to 9 percent, affecting customer tabs at restaurants, hotels, and now campgrounds. A similar style tax was proposed for all entertainment purchases, such as concerts, but that measure failed.  A new 10 percent tax on gambling winnings did make it through, along with a 45-cent tax increase on cigarettes.  Car and boat registration fees will double under the new plan, but toll increases stalled.  The committee also approved the sale of liquor at eight grocery stores in the state.

It wasn’t nickels and dimes that really balanced this budget, however.  A last-minute revision to expected tax revenue eliminated no less than $75 million in the budget shortfall.  And a move to bond $87 million in school funding took that much out of the operating budget, for a cost of $14 million in debt service per year.

Shaking Down

All in all, the $3.2 billion general fund is only about a third of the overall state budget.  With money from the federal government, education trust fund, highway fund and other sources, New Hampshire’s tab will come to about $11.6 billion in the next two years, combined.  Since those other sources are mostly dedicated funds for pre-determined spending, it’s the General Fund that gets the most attention.

The lion’s share of General Fund spending—nearly half—goes through the Dept. of Health and Human Services. General government costs follow at about one-fifth, with education and justice expenditures not far behind. The committee’s compromise budget includes a change that allows the Dept. of Corrections to implement a program designed to reduce criminal recidivism, thereby lowering inmate numbers and reducing personnel needs. Plans are already underway to close the state prison in Laconia.

A proposed 850-student cap on public charter schools has also been repealed, thanks to restoration of $6.6 million in aid to those schools.  The two-year moratorium on approving new charter schools remains in place, and state officials have been directed to investigate how future cuts in state aid to charter schools may affect New Hampshire’s standing with the American Recovery and Reinvestment Act.

New Hampshire’s Constitution requires a balanced budget. There’s no law, however, against using old numbers if you can’t figure out new ones.  If the conference committee’s budget fails, the Legislature would work off of the current (2008-09) biennial budget until a new compromise is reached.

The Senate will vote first on Wednesday, but opposition there remains strong among Republicans. This numbers game could last into summer.

Should the state lower spending, or start bringing in new money to balance the budget?
Share your thoughts below.

And remember, our online learning center and a complete list of proposed laws for 2009 is available here at Front Door Politics: from the State House to your house.

New Hampshire has about five months to get its books in the black before the end of the current fiscal year on June 30, 2009. Last fall, the state was an estimated $250 million over budget, mainly because it just didn’t bring in as much dough as it expected. Then, just before Thanksgiving, the Fiscal Committee approved several executive orders from Gov. John Lynch that saved about $175 million.

Last week, the House Finance Committee took on a chunk of the remaining $75 million deficit, and the full House will weigh in on their proposed cuts next week. Here’s a rundown of what’s in store.

Among the savings, the Dept. of Health & Human Services could bank $1 million just by changing a certain billing policy. The legislation would not in any way limit or change treatments available to Medicaid patients, stresses DHHS Medicaid Finance Director Marilee Nihan. Instead, HB 30 would clarify the definition of “outpatient services” vs. “physican services” eligible for Medicaid reimbursement. She explains that different payment procedures are used depending on how treatment is billed, and hospitals tend to get higher reimbursement rates for physician services. This new definition would provide a pretty broad scope of what’s considered “outpatient,” she says, so hospitals are none too happy about it.

And, the bill would reduce the general fund contribution to the highway fund by $5 million—down to $1,750,000. Although “any cut in funding hurts,” according to Dept. of Transportation’s Bill Boynton, this is not one that will ultimately affect DOT much, because only a fraction of the agency’s $600 million annual operating budget comes from the general fund. What does come from there goes to the Rail & Transit and Aeronautics bureaus, so HB 30 may be worse news for those arenas, but it won’t impact what’s top on most minds this season: winter maintenance and snow removal. That remains the agency’s first priority, according to Boynton.

About $10 million more would be restored to the general fund from further cutting the judicial and legislative budgets; limiting some retirement contributions; dipping into certain dedicated funds; shifting around the funding for some administrative positions; and pulling money from an HIV prevention program (see SB 67 for more on this issue).

If approved, HB 30 will still leave the state an estimated $59 million in the hole.

SB 67: renew HIV Protection Program funds
Martha Fuller Clark (D-Portsmouth)
Public Hearing Tuesday, Feb. 3, Senate Health & Human Services Committee

Funding for HIV/AIDS support programs has been a rocky road in New Hampshire the last two years, and people involved are still bracing for what may lie ahead. The passage of SB 67 would continue current funding at $1 million per year. But, one of the same programs that the bill would maintain is on the chopping block with HB 30’s proposed state budget cuts.

For two years, New Hampshire has spent $500,000 annually on the purchase of antiretroviral drugs, and another $500,000 per year on what Richard Wagner, the executive director of AIDS Response Seacoast, calls the “care portion.” By that he means services like promoting healthy lifestyles and sticking to medication schedules, transportation assistance for medical appointments, and budgeting help, among others. The legislation that created this funding is tied to the biennial budget; in other words, the programs are funded for only two years at a time.

Enter House Bill 30, which would cut 2009’s $500,000 allowance for the program that buys HIV/AIDS medications. HB 30 doesn’t touch the care portion, so as long as the Dept. of Health & Human Services can find another way to fund that medication program, Wagner isn’t too worried—yet.

But, SB 67 is the 2009 bill that would extend the drug and care programs for the next two years, 2010 and 2011. And although Wagner reports good support for the bill in the Senate, he remains concerned. “If this funding is cut, it’s going to be a disaster for people living with HIV and AIDS in the state,” he says.

Without the funding, Wagner predicts, patients will end up sick, at the hospital, and on welfare. “Somebody’s going to have to pay for it somewhere down the line,” he says, and it’s not just about treatment. He doesn’t expect emergency rooms and welfare offices to address the broad lifestyle issues that programs like his employ to keep patients, well, as healthy as they can be.

Thoughts? Share them below!

And remember, our online learning center and a complete list of proposed laws for 2009 is available here at Front Door Politics: from the State House to your house.

© 2009 Niles Media “Front Door Politics” all rights reserved

The committees are made, bills introduced and seats assigned. The NH House and Senate took their formal start for 2009 on Wednesday, Jan. 7, one day before Gov. Lynch’s inauguration.

And there’s no time to waste, as public hearings start next week on the nearly 1000 bills up for debate this session.

But, there’s some orienting to be done before all the work can get started. A slew of organizational and informational meetings started up last week, many of which involved the state agencies within each committee’s sector. Many, but not all.

better, but worse first

The Senate Finance and Ways & Means committees met Wednesday for a budget presentation by the Center for Public Policy Studies, a Concord, NH-based private sector think tank. The short version of the Center’s message: things are going to get better, but they’re going to get worse first.

Center director Steve Norton’s presentation related the state’s thin wallet to unemployment, a high rate of property foreclosures, and the low value of housing, among many other factors. The predicted $500 million shortfall for the 2010-11 budget cycle will follow a budget that’s already trimmed close to the bone. That means “significant program impact” will probably be unavoidable, according to the report, and it’s going to take big policy changes to get back in the black.

That could mean reinstituting time off for good behavior in the state prison system, limiting who is eligible for Medicaid, or lowering the state’s contribution to retirement savings for non-state employees (such as teachers, police and fire personnel). But, as the Center’s deputy director Denis Delay put it, “Saying that you can change rules that will save money is not the end of it. The cities and towns will have something to say … possibly in courts.”

And that is why, Norton stresses, if the Legislature wants to control spending in the next biennium, they’ll need to start planning now.

Gov. Lynch will present his proposed budget to the Legislature in February.

public hearings next week:

House committees are scheduled to hear a total of 55 bills next week, while the Senate is looking at 12. Following is a short selection of bill titles with their prime sponsors, hearing dates, assigned committees and brief analyses. More complete information is available at www.frontdoorpolitics.com.

HB 171 “establishing a commission to evaluate mental health courts and establish standards for the operation of mental health courts,” Cindy Rosenwald (D-Nashua)

Tuesday, Jan. 13, House Judiciary Committee

Mental health courts were established in NH in 2005 as a pilot program in Keene, and have since grown to operate in Nashua, Rochester and Portsmouth. A prime goal of the courts is to improve access to community-based mental health treatment programs for nonviolent criminal offenders, with the hope of reducing recidivism rates and improving public safety.

The 10-person commission established by this bill would consist of two House members, one Senator, a designee from the Department of Health and Human Services, a district court judge, a prosecutor from a county attorney’s office, an attorney from the Office of the Public Defender, a representative of the Disabilities Rights Center, the chief executive of a community mental health center and a representative of the NH division of the National Alliance on Mental Illness.

The act would become effective upon passage, requiring an interim report from the commission by Nov. 1, 2009, and a final report one year later.

HB71 “relative to increasing the dollar limit for requiring public hearings on issuance of local bonds,” Betsey L Patten (R-Moultonborough)

Wednesday, Jan. 14, House Municipal and County Government Committee

This bill raises by ten times (from $100,000 to $1,000,000) the dollar value of proposed municipal bonds or notes that require a public hearing.

Current rules require that public hearings on any such proposal be held 15-60 days before the matter is voted on; notice of the time, place and subject of the public hearing must be published at least one week in advance. These specifics would remain in place.

This bill would change only the dollar amount that triggers the public hearing requirement.

This act would take effect 60 days after its passage.

HB62 “requiring young women under 15 years of age to provide proof of counseling prior to obtaining an abortion,” Anthony R DiFruscia (R-Windham)

Thursday, Jan. 15, House Judiciary Committee

According to the text of this bill, proof of counseling would be a document signed and dated by the young woman and her counselor that would then be sealed or notarized at least 48 hours before being submitted. The counselor in question could be a parent, adult sibling, adult aunt or uncle, grandparent, or certified religious counselor; a person associated with a licensed abortion provider would not be eligible.

If is is passed, the requirement would take effect within 60 days.