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Monthly Archives: March 2012

The Department of Aging and Disability Services (DADS)in Texas  is asking for feedback about its Legislative Appropriations Request (LAR) for the 2014-2015 biennium.  This will be another difficult budget time between state financial concerns and the Federal government budget concerns.  Below is the feedback that I provided to DADS.  Some of this is taken from the earlier comments I had on SB7.

 Thank you for the opportunity to provide input on DADS’ LAR for fiscal years 2014-2015. I am a parent of an almost five-year old with Down Syndrome. I have also been appointed as a parent member to the Children’s Policy Council (established by HB 1478 of the 77th Legislature), the Task Force for Children with Special Needs (established by SB 1824 of the 81st Legislature), and the Early Childhood Intervention Advisory Committee. Not only am I living this as a parent, but I’m also involved in attempting to change things to provide better services to children like my son.

I think there are a number of areas where DADS can provide leadership via this LAR:
• HMA’s Pilot to Serve Persons with Intellectual and Developmental Disabilities
• LBB’s 2011 report on “Transform State Residential Services for Persons with Intellectual and Developmental Disabilities”
• Integration of planning
• Senate Bill Seven
• Stakeholder Input

HMA Pilot:
Health Management Associates issued a report in October of 2010 recommending establishing a pilot program using a non-capitated enhanced care management model for individuals with intellectual and developmental disabilities. The idea being that this can result in cost savings, open up additional waiver slots, and eventually (hopefully) lead Texas down the road to these services becoming entitlements like in other states. DADS should include this in the LAR (and in associated budget presentations) to get this pilot program funded for the biennium and lay the groundwork for possible future expansion of the program.

LBB 2011 Report:
Prior to the 2011 Legislative session, the Legislative Budget Board issued their report calling for a number of changes to the state supported living centers. Their recommendations were:
1. Include a rider in the general appropriates bill directing DADS to close at least one SSLC
2. Include a rider requiring DADS to submit a closure plan
3. Include a rider to authorize DADS to reclassify one FTE position to direct the closure process
4. Amend the Health and Safety Code to establish a realignment/closure commission (for SSLCs)

These recommendations did not go anywhere in 2011. If DADS were to provide leadership, include this in its LAR, and champion these recommendations this would go a long way towards giving DADS the flexibility to modernize its services in this area.

Integration of Planning:
It is important that future planning with regards to health care, Medicaid, and the improvement of services for individuals with special needs must be integrated. Often, these planning efforts are disconnected or driven by whim and this ensures that they will fail. Committees can draft reports, they can develop plans, but if they are not integrated and supported by the state agency strategic plan and the Legislative Appropriation Request then they are doomed to failure.

Senate Bill Seven:
Senate Bill 7, passed by the 2011 Legislature in special session, serves as an example of increasing government waste and inefficiency while attempting to reduce it. The bill seeks to reduce Medicaid and health care issues impacting children with disabilities to a handful of outcome measures in order to simplify an enormously complex problem. In so doing, it requires no less than 14 different reports, studies, and assessments and sets up new government entities that will require ongoing funding diverted from areas that could be providing direct services to children with disabilities.

Each of the reports that SB7 requires (some are for the Legislature, some for the Governor, most are for both) will require staff time to collect data, analyze data, compile reports, brief agency officials, and prepare agency officials for Legislative testimony. Each of these reports will lead to situations where state agencies will seek new streams of information from health care providers in order to satisfy the needs of the reports for data. The combination of all of these efforts will mean that more resources are being devoted to collecting, analyzing, and reporting data rather than providing services to children with special needs. While the Legislature’s desire for knowledge is admirable, I question how influential this data will ultimately be in the decision-making process.

SB7 also requires a number of studies by HHSC and DADS. These are described in sections 1.02 (patient centered medical homes, external quality reviews, payment incentives), 1.09 (physicians incentives), 1.12 (performance incentives based upon outcome and process measures), 3.01 (outcome measures of quality and efficiency), 6.05 (preventable events for hospitals/long-term care facilities), 6.07 (data by facility), and 6.08 (study on incentives and recognition of health care quality). While the intent behind these studies is admirable, they will result in health care providers spending more time and resources on these and less on direct services and it is unclear that these studies will uncover any information that is not already known.

DADS should educate the Legislature, via the LAR, about the hidden costs and ripple effects that this kind of micromanaging has.

Stakeholder Input:
I appreciate DADS soliciting stakeholder input on the LAR. Often, stakeholder input is solicited towards the end of planning instead of at the beginning. I would like to encourage DADS to continue soliciting stakeholder input at the beginning and during the planning process, rather than just with the final product.

Below is from a letter that I sent to a number of Texas legislators concerning Medicaid reform in Texas:

Between the passage of Senate Bill 7 in the last special session, federal and state budget challenges, and the many hearings that are currently taking place in the Legislature, there are significant changes to health care as it impacts children with special needs in Texas. I am writing this letter because I have concerns that the Legislature, while having good intentions, is missing several important opportunities in their current efforts to combat inefficiency, rein in costs, and still provide services to children with special needs.

I am a parent of an almost five-year old with Down Syndrome. I have also been appointed as a parent member to the Children’s Policy Council (established by HB 1478 of the 77th Legislature), the Task Force for Children with Special Needs (established by SB 1824 of the 81st Legislature), and the Early Childhood Intervention Advisory Committee. Not only am I living this as a parent, but I’m also involved in attempting to change things to provide better services to children like my son.

Senate Bill 7, passed by the 2011 Legislature in special session, serves as an example of increasing government waste and inefficiency while attempting to reduce it. The bill seeks to reduce Medicaid and health care issues impacting children with disabilities to a handful of outcome measures in order to simplify an enormously complex problem. In so doing, it requires no less than 14 different reports, studies, and assessments and sets up new government entities that will require ongoing funding diverted from areas that could be providing direct services to children with disabilities.

Each of the reports that SB7 requires (some are for the Legislature, some for the Governor, most are for both) will require staff time to collect data, analyze data, compile reports, brief agency officials, and prepare agency officials for Legislative testimony. Each of these reports will lead to situations where state agencies will seek new streams of information from health care providers in order to satisfy the needs of the reports for data. The combination of all of these efforts will mean that more resources are being devoted to collecting, analyzing, and reporting data rather than providing services to children with special needs. While the Legislature’s desire for knowledge is admirable, I question how influential this data will ultimately be in the decision-making process.

SB7 also requires a number of studies by HHSC and DADS. These are described in sections 1.02 (patient centered medical homes, external quality reviews, payment incentives), 1.09 (physicians incentives), 1.12 (performance incentives based upon outcome and process measures), 3.01 (outcome measures of quality and efficiency), 6.05 (preventable events for hospitals/long-term care facilities), 6.07 (data by facility), and 6.08 (study on incentives and recognition of health care quality). While the intent behind these studies is admirable, they will result in health care providers spending more time and resources on these and less on direct services and it is unclear that these studies will uncover any information that is not already known.

Given the budget situation in the state of Texas I am concerned that by establishing the Texas Institute of Health Care Quality and Efficiency, SB7 will be diverting funding from state agencies that provide services to children with disabilities and using it to fund a new entity that does not provide any services.

As the members of the Legislature know, Early Childhood Intervention (ECI) due to funding challenges, moved to a model of shared costs and personal accountability similar to what is described under Article 13 of SB7 for Medicaid reform. This is having a damaging effect on providers of ECI services and access to ECI services.

It is critical that as the state of Texas moves forward with changes to Medicaid and health care, that stakeholder input be sought early enough that stakeholders can impact the process. Frequently stakeholder input is sought at the end of the process, once the state agencies have developed the final product. At this point, input is too late and important things will be missed. For example:
• On March 1, HHSC changed the dental Medicaid program to a managed care model. But in so doing, did not account for the fact that many children with special needs have to be treated in a hospital setting because there is a shortage of dentists who are wiling to accept and treat children with special needs. In addition, there are serious complications that involve balancing between the Medicaid model (which can often be a secondary insurer) and a primary insurer. Had stakeholder input been sought early in the process these issues could have been anticipated and addressed.
• On March 1, HHSC changed the model for providing pharmacy services to children enrolled in STAR, STAR+PLUS, and CHIP. This model failed to account for the fact that children with special needs may require medically necessary drugs not on the preferred drug list, may need compounded drugs, may need home delivery of prescription drugs, may need specialty pharmacies, may need medical equipment through their pharmacy, etc. Had stakeholder input been sought early in the process, these issues could have been anticipated and addressed.

This should also be done in terms of any strategic plans and Legislative Appropriation Requests. I urge the Legislature to require the health and human services agencies to solicit and incorporate stakeholder input early and often in their planning process, well before any finished product is rolled out.

Finally, it is important that future planning with regards to health care, Medicaid, and the improvement of services for children with special needs must be integrated. Often, these planning efforts are disconnected or driven by whim and this ensures that they will fail. Committees can draft reports, they can develop plans, but if they are not integrated and supported by the state agency strategic plan and the Legislative Appropriation Request then they are doomed to failure.

Thank you for your time, thank you for your service to Texas in undertaking this complex and difficult matter.