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Monthly Archives: November 2013

Yesterday I attended the Early Childhood Intervention (ECI) Advisory Committee meeting in Austin. These meetings are always informative and important because ECI has experienced huge, fundamental changes over the last four years and it is not done. Over the last four years, ECI has narrowed its eligibility which has changed the population of children receiving ECI services, it has required ECI providers to directly bill Medicaid and insurance companies to get reimbursed for services which has required them to develop new skill sets, and it has begun requiring families to pick up some of the costs of the ECI services which has some far-reaching effects.

I’m going to use this post to talk about several things:
• Senate Bill 1060
• Annual performance report data
• Senate Bill 7

Senate Bill 1060
Senate bill 1060 requires the Department of Assistive and Rehabilitative Services (DARS) to study the cost effectiveness of the family cost share system in ECI. Now, the bill is a little more than a study. The bill directs DARS to study the cost-effectiveness of the system and also to evaluate the changes necessary to improve the cost-effectiveness of the family cost share part of ECI. DARS will also implement those changes if they improve the cost-effectiveness and if they don’t hurt access to the services. This will all be done by December 1, 2014. So part of the meeting yesterday dealt with the fact that this study is going to begin soon.

The family cost share idea sounds really good on the surface. Those families that are able to pay for the services should. However, when families are asked to do either pay out-of-pocket or to use their insurance to cover ECI services, it introduces something unexpected – competition. Those families with the means may begin going to private providers for speech therapy, occupational therapy, and physical therapy as opposed to an ECI provider. This has a number of interesting potential impacts. First, private providers aren’t providing services in the child’s natural environment which is a huge advantage that traditional ECI has. Second, private providers are “fixing” the delay as opposed to coaching the family to help the family be successful, which is another huge advantage that traditional ECI has. Finally, if this happens on a large enough scale it is unclear if traditional providers can adjust to this change.

Annual Performance Report (APR) data
DARS is required to submit an APR to the federal government each year as a condition to renew the federal funding for ECI. There are a lot of measures in this report and I’m usually the one that does the most arguing over the statistics and their meaning. Anticipating this, DARS reported on the data at a meeting that was earlier than usual. While there are a lot of measures, the focus is usually around the impact of ECI on children and the impact on families.

The data looking at the impact of ECI on children shows that more children than ever make improvements as a result of the ECI program, but we’re losing ground in terms of how many of these children are reaching an age-appropriate level as a result of the ECI intervention. The DARS staff felt there were two major reasons for this. First, the quality of the data is improving. In other words, this might be a more accurate reflection. I’ve actually heard that the data is improving for several years now. At some point we have to quit using this one.

Second, because eligibility was narrowed this changes the children in the program so that they have more complex needs. I asked the staff when the eligibility was narrowed, because this actually happened two and a half years ago – in other words, last year to this year might be looking at apples to apples. The staff felt that there was a transition period during which you had children under the old eligibility requirements comingled with the new requirements, so you are looking at different populations. The chair of the committee had a great suggestion about running the historical data incorporating the current eligibility requirements to see where we are compared to where we were.

The family outcome data is based upon a survey and shows overwhelmingly that ECI is a valuable service for families. The challenge with this is always that there are approximately 25,000 children in ECI and the data is based upon something like 600 surveys, which is about 2.5% of the population. I don’t have any issues (and am glad) that the surveys are extremely positive about the impact of ECI on families, I just always wonder how representative the sample is of the entire population. The DARS staff assured me that this was a representative sample size.

Senate Bill 7
Senate bill 7 passed in the last legislative session and is slowly moving individuals with intellectual and developmental disabilities away from the Medicaid waivers and to managed care. This impacts ECI because SB7 establishes Star Kids, which is the form of managed care for children. At the meeting yesterday we had a presentation from the Health and Human Services Commission (HHSC) staffer that is coordinating this. And she got an earful. Essentially HHSC will develop the broad guidelines, services, etc. and will then request that managed care organizations submit proposals on piloting this program. During what was meant as a high-level presentation on Star Kids, parents and one school district staffer submitted feedback about SB7 and Star Kids:
• Managed care organizations are used to treating medical problems. For example, if you break your leg it is generally treated in a certain way and generally takes a certain amount of time to heal. If it’s bad enough, based upon an assessment, you may require some physical therapy to become stronger/regain your balance/etc. All this is measurable. People with IDD don’t necessarily have medical conditions. They are complex, have changing needs, and this model won’t work with them – they aren’t being treated.
• Managed care organizations that ultimately end up providing these services are clearly not doing this out of the goodness of their heart, they are seeking to make money. There’s nothing wrong with this, unless it’s your loved one who isn’t receiving services in the interest of the company’s profit.
• Any managed care organization(s) selected should have experience working with people with IDD.
• It needs to be recognized that if there are a handful of managed care organizations providing services in Texas ultimately, each will be offering slightly different services and have slightly different ways of doing things which parents and caregivers aren’t going to understand.
• Finally, there was a discussion about why didn’t SB7 and Star Kids think about the services the children are receiving in the school system? This actually has some implications. Some kids in this population may be receiving speech therapy, physical therapy, occupational therapy, have an assistant, communication/mobility aides, transition, even specialized nutrition through the school system. How does this link up with the services that Star Kids provides? What about case management? What about transition?