HMPs: What they do, what they spend

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The “Don’t smoke” posters in the local high school hallway?

The convenience store clerks trained to check IDs so kids don’t buy beer?

The new walking path in town?

It’s likely that an HMP — a Healthy Maine Partnership — had something to do with each of those things, and more.

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Despite all the good done, for nearly two years the state’s Healthy Maine Partnerships program has been the focus of controversy, with accusations of document shredding and of state officials playing favorites with millions of dollars.

The state’s Office of Program Evaluation and Government Accountability found a host of problems with the Maine Center for Disease Control & Prevention’s handling of the grant awards to the partnerships. The Legislature’s Government Oversight Committee has been seeking answers for months. A former CDC official has filed a whistle-blower lawsuit in federal court alleging she faced harassment and retaliation when she refused to destroy documents connected to the partnerships’ funding.

But while the controversy continues to swirl, the state’s Healthy Maine Partnerships have quietly gone about their business.

What, exactly, do they do? And what has that money been spent on?

The Sun Journal analyzed the funding contracts for all nine groups for fiscal years 2013 and 2014 to find out.

What is an HMP?

Except for Portland and Bangor, most Maine cities and towns don’t have local health departments. They rely on HMPs — independent, local, public or nonprofit coalitions — to protect and promote public health.

Twenty-seven HMPs, including nine lead ones, cover Maine’s eight public health districts — areas outlined by counties and regions. As required by state law, one HMP covers the state’s tribal health district and is responsible for serving the people of Maine’s four federally recognized tribes. 

HMPs can seek federal and other grants, but they typically received much of their funding from the state through the Fund for a Healthy Maine, which was established with tobacco settlement money. The state has asked HMPs to place a lot of their state-funded focus on establishing a public health infrastructure and working on reducing tobacco use, increasing physical activity and other health issues.

In 2012, the state cut a third of the HMP program’s funding, reducing it to $4.7 million a year. To compensate, the CDC decided to name nine lead HMPs, one in each of the eight public health districts and one serving the tribal nations. The new lead HMPs got dramatically more money and more responsibilities, while the others saw their funding slashed.

Leads got between $483,000 and $723,000 each fiscal year 2013 and 2014, including some federal money for substance abuse work. They became responsible for passing through a chunk of that funding to the HMPs under them. 

The tribal HMP is unique. It sits within the Wabanaki Public Health District and, although it is classified as a lead, there is no other HMP under it.

Its contract is unique, too. Unlike the other lead HMPs, the tribal group got money for its whole district — the Wabanaki Public Health District — and the sole HMP within it.

Together, the tribal district and HMP received just under $600,000 each year, including the federal substance abuse funds.

While the directors of all other HMPs spoke in detail about the population their HMP serves and the biggest health issues that population faces — generally obesity, smoking and chronic disease — the head of the tribal group would not.

Director Kristi Ricker declined to be interviewed and answered only some questions sent by email. She did not answer questions about the number of people served and refused to answer questions about the health issues that the tribal health district and its HMP are trying to tackle.

“I am not at liberty to discuss tribal health data, including the health disparities of our population,” she said in an email. “The health assessment results are owned by each tribe and only released when requested through and at the discretion of tribal leadership.”

However, she did say the Wabanaki Public Health District has been working toward completing its district public health improvement plan, developing the Wabanaki Public Health infrastructure and completing assessments of the tribal communities. She said staffers are focused on increasing membership and creating coalitions in each tribal community to develop community health improvement plans and the district will conduct a local public health systems assessment.

Sub-awards

Sub-awards account for the largest part of each lead HMP’s contract, ranging from $45,450 with the tribal group to $585,800 with the Greater Somerset Public Health Collaborative in Skowhegan.

Leads give sub-awards to the HMPs that sit under them. The greater number of HMPs that sit under a lead, the more money that lead gives out. Except for the tribal group, each lead has between one and three HMPs under it.

Those sub-HMPs are expected to perform many of the same functions as a lead, but with fewer administrative and reporting responsibilities.

The River Valley Healthy Communities Coalition in Rumford has three HMPs under it, including Healthy Androscoggin in Lewiston. It gave out more than $500,000 each year to its subs — more than 70 percent of its HMP funding.

“We’re all pretty much expected to do the same work no matter how much (money) we have,” said River Valley Director Patricia Duguay. “I’m always looking at what’s fair. If we all have the same objectives on us, I think the funding should kind of equal that.”

She said she gave her HMPs their state-allotted base amounts, set aside some money for her lead HMP’s administrative responsibilities, then, “I basically took what was left over and split it four ways. It wasn’t rocket science. I don’t know how, quote, professional or unprofessional that was, but I felt that was the fairest way.”

According to the contracts, the tribal group gave the bulk of its sub-award money to Wabanaki Health and Wellness, a nonprofit group that provides health and wellness services to tribal members. It also gave money as grants to law enforcement for Enforcing the Underage Drinking Laws Program and as part of a youth mini-grant and scholarship program.   

Personnel

After sub-awards, paying staff costs HMPs the most.

Total salary expenses ranged from $77,000 at the Greater Somerset Public Health Collaborative to just about $227,000 for the tribal group, which includes both the whole public health district and its HMP. 

Total personnel benefits ranged from just over $13,000 at River Valley to just over $83,000 with the tribal group. That benefit amount includes FICA and Medicare tax, unemployment insurance, workers’ compensation, health insurance and retirement.

HMPs generally have a handful of people working for them.

According to the contracts, workers have a host of responsibilities as part of the HMP grant, including coordinating programs, promoting health initiatives and meeting with community groups and businesses to develop partnerships.

But while individual staff members get part of their salaries from the HMP grant, they may not get it all from there. Staff members often work on different grant projects at the same time and their salaries are paid with those grants.

Directors, for example, may spend 25 percent of their time on HMP work and get 25 percent of their paycheck from HMP money. The rest of their compensation is made up of other state, federal or private grant projects on which they are also working.

According to the most recent contracts, directors earned between $40,500 — at Greater Somerset — and about $79,000 — at Healthy Acadia in Bar Harbor. (Healthy Acadia’s director contracted to work the equivalent of 72 days for the HMP grant and and took just under $22,000 in HMP salary for it.)

Travel

Travel expenses — mileage, hotels, per diems for meals and incidentals, etc. — didn’t cost nearly as much as personnel or sub-awards, but they can be significant and integral to the HMPs’ ability to do their work. Travel expenses also showed some of the greatest contrast among HMPs.

Some leads asked for $2,000 or $3,000 a year for travel to meetings, trainings, outreach work and events. Others, including those that serve Androscoggin, Oxford and Franklin counties, Aroostook County, Down East and the Bangor region, requested $5,000 to $10,000. The HMPs with the highest travel expenses also cover some of the widest areas.

One, the tribal group, asked for tens of thousands of dollars in travel.

The Wabanaki Public Health District as a whole allocated more than $51,000 for travel in 2013. Of that, according to Ricker, nearly $31,000 went to the tribal district’s HMP.

The district as a whole allocated more than $53,000 for 2014. Ricker said just nearly $31,000 of that was dedicated to the HMP.

That’s at least three times more than any other HMP contracted to spend on travel.

Ricker pointed out that “there is extensive travel involved in the district which we serve” and said all five employees are required to travel due to the spread of the region they cover.

“We are seated in Houlton, Maine, our closest community is 90 miles round-trip from here, and the farthest is 228 miles round-trip, and a trip to Augusta is 400 miles round-trip. We have to spread our time equally across the communities we serve, as well as fulfill our commitments to Maine CDC and SAMHS (Office of Substance Abuse and Mental Health Services),” she said in an email.

“We attend three District Coordinating Council meetings a quarter, one in each of the districts our Tribal lands reside, as well as our own quarterly Tribal Health Directors meetings, which is the Tribal Public Health District’s DCC (District Coordinating Council), per legislation,” she wrote.

Although the contracts provide some detail about how the travel money is spent, they do not break out how much went to the district as a whole and how much went to the HMP specifically.

Of the more than $51,000 for both public health district and HMP travel in 2013, the contract set aside $18,900 for two people to travel 41,818 miles, $4,500 for hotels and $4,820 in per diems. It does not detail where the remaining $23,000 in travel would be spent.

Ricker said the tribal group usually uses hotels for travel to areas south of Bangor, multi-day meetings or back-to-back travels. Per diems, she said, are paid for all travels, either day or overnight, and are calculated by the quarters of the day. Most travels, she said, are half-days.

Of the more than $53,000 for travel in 2014, the contract sets aside $30,404 for four people to travel 69,100 miles to meetings, outreach and workforce development. Ricker said 41,100 of those miles are for the HMP specifically.

Within that $53,000, the contract also sets aside $3,950 for training, conferences and membership fees, nearly $5,700 for hotels and just over $7,700 in per diems.

Ricker said the HMP is responsible for $3,544 of the hotel expense and $4,289 of that per diem.

That travel account also was earmarked to pay for two people to go to Boston for an annual American Public Health Association conference ($1,050 in registration, $330 in mileage, $80 for train fare, $450 for the hotel and $426 in per diem).

Ricker said the tribal group budgeted for both mileage and train fare because, “We drove to the conference, but had put in for fare to ride the T, which seemed more efficient since we didn’t know our way around the city. Once there, we realized that there were shuttles provided from the hotel to the conference.”

Travel money was also earmarked to send someone to the quarterly Region One Health Equity meetings in the Boston area ($1,540 in mileage, $1,000 for hotel and $568 in per diem). Ricker said that trip is for the health district as a whole, not its HMP, and it is part of National Partnership for Action under the U.S. Department of Health and Human Services, “a public-private initiative that seeks to mobilize a nationwide, comprehensive, community-driven and sustained approach to combating health disparities and to move the nation toward achieving health equity.”

Said Ricker of the per diem: “At a rate of $46 per day for most areas we travel is equal to 93 full days. We are only paid for the actual quarters of the day which we are on approved travel. This is set by the U.S. General Services Administration rates and based on the breakdown of $7 breakfast, $11 lunch, $23 dinner and $5 for incidentals per day.”

For hotels, she said, the group pays the federal government rate, “between $77 and $97 per night, this is equal to approximately 40 nights.”

Consultants

Like travel expenses, consultants didn’t cost as much as personnel or sub-awards, but they could be a significant expense. The consultant expense, too, showed contrast among HMPs.

Three lead HMPs asked for no money to pay for consultants in either 2013, 2014 or both. Four asked for between $10,000 and $19,000, most often to pay for help with public health planning, Responsible Beverage Seller/Server training or help coordinating district council meetings.

Other consultant requests were more unique. As part of its consultant budget, the Coastal Healthy Communities Coalition, overseen by the University of New England, asked for $1,000 for a breastfeeding policy consultant to help make more York and Cumberland county locations friendly for breastfeeding mothers.

Two HMPs asked for $30,000 or more for consultants. 

The tribal group, which, again, includes both the Wabanaki Health District as a whole and its HMP, earmarked $5,000 for consultants in 2013. That jumped to $32,000 in 2014.

Ricker said the tribal HMP, which formed only two years ago, needed the help as it became fully staffed in 2014 and sought to focus more on infrastructure, capacity building and completing the planning process for improving community health.

“Even though every other district was in existence for a decade longer than ours, we are currently performing at the same level, completing the same work plan while continuing to build infrastructure and completing the MAPP (Mobilizing for Action through Planning and Partnerships) process,” she said in an email.

That consultant spending included $16,000 to University of Nebraska to compile community profiles of the tribes and $6,000 to an evaluator for a Wabanaki health systems assessment.

It also included $10,000 to pay the tribal HMP’s former director, Clarissa Webber, $30 an hour to serve as the tribal public health planning and coordination consultant. However, Webber returned to the HMP as a public health liaison last October and a new consultant was hired. That new consultant is now focused on getting the tribes’ community profiles, along with the consultant from the University of Nebraska.

Healthy Acadia, which serves Down East, earmarked the most for consultants: $35,000 in 2013 and $46,000 in 2014.

In 2013, that $35,000 included: $5,000 for a community engagement consultant, $5,000 for a health planning consultant, $5,000 for a municipal planner, $5,000 each for two substance prevention consultants, $3,000 for a responsible server consultant, $2,000 for a website consultant and $1,000 for a board development consultant.

In 2014, that $46,000 included: $16,500 for a health planning consultant, $9,500 for community outreach consultants, $7,000 for substance prevention consultants, $4,000 for a community engagement consultant, $3,500 for a governance and organizational consultant, $3,000 for a responsible server consultant and $2,500 for graphics and media design. 

Healthy Acadia’s business manager said most of those consultants deal with planning and infrastructure development — such as overseeing an advisory board made up of  more than 50 community leaders, health advocates and residents to help keep the HMP’s health programs “burrowing into the communities.”

“It’s invaluable. It’s the infrastructure that allows these programs to have a chance at sustainability going forward,” Sandy Johnson said. “The infrastructure work is to kind of build the relationships and the sustainability of these programs throughout the communities.”

Indirect costs

Most of the state funding pays for the HMPs’ direct expenses, things like brochures, training materials and staff to run programs — everything that helps a health coalition do its work.

But indirect expenses — for things that help the coalition exist but don’t directly impact its work  — also come up. Things like rent, administration, accounting and someone to handle human resources. 

The tribal group showed the most indirect spending: just over $140,000 in 2013 and just under $101,000 in 2014. It’s unclear how much of that went to the tribal health district as a whole and how much went specifically to the HMP.

When asked about indirect expenses, Ricker said in an email only, “The indirect rate decreased from FY13 to FY14.”

Five of the remaining HMPs set aside between $18,000 and $56,000 for indirect expenses.

Because they also accept federal grant money for projects, a number of those HMPs have federally negotiated rate agreements that mandate a specific percentage of funding go to indirect expenses.

Healthy Acadia, for example, maintains an indirect rate of 21 percent. That means the group subtracts most of the money it gives away for sub-awards and then sets aside 21 percent of the remaining funding for indirect expenses. In 2014, that amounted to just over $56,000.

Johnson, the business manager, said such a set percentage makes indirect spending consistent across grants and easier to deal with.

“It’s certainty,” she said. “A lot of these are cost reimbursement contracts, and if you don’t know for sure until you get audited whether or not an expenditure is going to be allowed — whether it’s direct or indirect —  it makes it very difficult to have some certainty in your financial administration.”

In its contracts, the tribal group listed an approved indirect rate of just over 32 percent in 2013 and just over 22 percent in 2014.

Three HMPs — Healthy Aroostook, Bangor Region Public Health and the River Valley — showed no indirect expenses. Officials at all three said they spend money on administration, but they allocate those costs differently than the others.

River Valley, for example, pays for rent, phones and other items out of its general budget, not out of the grant it gets as an HMP.

“We’re a very basic, simple organization,” Duguay said. “We may have to look at an indirect rate down the line as we continue to grow, but where we’ve been small all these years, we’ve been able to cover those costs in the body of the budget itself.” 

ltice@sunjournal.com

Source: Maine Department of Health and Human Services contracts with Healthy Maine Partnerships
* HMP head is overseen by a director paid by another entity
** HMP director’s salary includes a $2,400 tipend for health insurance
*** Unlike the other lead HMPs, the tribal group received money for its whole district — the Wabanaki Public Health District — and the sole HMP within it.
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