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Two identical bills have been filed in the Texas Legislature relating to Early Childhood Intervention (ECI).  The first is HB 1098 by Rep. Zerwas, the second is SB 1060 by Sen. Nelson.  These bills read like it is their desire to make ECI profitable.  As I read them, these bills have two parts. The first part (section 117.077) requires the Department of Assistive and Rehabilitative Servcies (DARS) to study the cost-effectiveness of the family cost share system of ECI.

As background, after the budget cuts in the last legislative session, DARS adopted a sliding family cost share for ECI based on family income.  This was one of their strategies to continue prvoding services in the face of the budget cuts.  The first part of this bill reads like it’s attempting to make ECI profitable (cost-effective means that family cost share revenue is greater than total administrative costs):
• DARS is required to collect data which lets them determine this information and evaluate the cost-effectiveness of the program.
• DARS is required to consider changes to make the program more cost-effective but may decline to make them if DARS does not feel that these changes will make the program more cost-effective.
• DARS is required to report on this by December 2014.

Now, this section gives DARS some wiggle room:
• “Total administrative costs” is not defined in the legislation. For example, is that the cost of DARS oversight? Or is it ECI provider expenses for providing the service (therapists, front office staff, case supervision, etc)? Or just partial expenses of providing the service (for example, only office staff but not therapists)? Etc.
• If DARS does not judge it possible to make the program profitable they do not have to implement the changes.

The second part (section 117.078) is a little more concerning and instructs DARS to consider implementing family cost share provisions based upon the family’s size and adjusted gross income with families in higher income brackets being required to pay more that those same families paid before this bill’s implementation. This family cost share is already in progress based upon family income, but I’m reading this as a requirement to increase those amounts. Now, the legislation instructs DARS “to consider” doing this, as opposed to saying that DARS must do this, so there’s some wiggle room. But the legislation represents the Legislature’s philosophy that families should be paying for more of these types of services.

The Legislature is seeking new ways to provide these services as well as the Medicaid services.  The idea being to control expenses and provide more services to more people.  In this legislation, the intent is to use the profits of the family cost share to provide more services to more children.  HB 1098 is being heard in the Human Services committee of the House on Tuesday, 3/12/13.

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Today I spent the day in Austin, largely at the state capitol.  This was an interesting day as there were a number of things happening:

  • Task Force for Children with Special Needs meeting
  • Senate Bill 7 hearing
  • Visits with legislators

Task Force for Children with Special Needs:

The Task Force is established by legislative statute and is a state-agency driven entity.  It’s purpose is to develop a strategic plan to meet the needs of children with special needs and is meant to integrate all the Health and Human Services agencies as well as agencies like the Texas Education Agency.  I was appointed by the executive commissioner of the Health and Human Services Commission as a parent member.  As a parent, I don’t get to vote but I do get to offer plenty of input, sometimes more frankly than the agency staffers are used to.

This was a short meeting because of the Senate Bill 7 hearing.  Basically it was to brief us on the Task Force’s two big initiatives.  The first is a comprehensive website, geared towards families, of the services available to children with special needs.  It’s meant to be a parent-friendly umbrella website that is easy to navigate.  More than that, it will have videos, information on developmental milestones as well as programs/services available by age (i.e. help prompt parents for the things they don’t know to think about), location of programs/services, etc.  It is also meant to have a regional component to help direct the parent to resources in their area.  The Task Force implemented a state wide research effort using focus groups, phone calls, and surveys and now the design of the website is in progress (funding for everything has been secured or is in progress with the current Legislature).

The second initiative is a crisis prevention/intervention service that would incorporate multiple agencies.  This is in the beginning stages of planning but it’s very needed and a great idea.

Senate Bill 7 Hearing:

DADS conducted a hearing on Senate Bill 7 this morning that ran at the same time as the Task Force meeting.  I decided ultimately not to attend this as I felt I’d be more impactful visiting legislators at the capitol (more on this later).  I’ve written everybody about my thoughts about this bill and I think the decisions have already been made on this one…

Visits with Legislators:

I spent about four hours visiting legislators, staffers, and committees.  I visited with mine, Sen. Paxton (staff) and Rep. Sanford (both the representative and his staff).  In addition I visited with Rep. Carter (staff) from Dallas, Rep. Raymond (staff), Sen. Nelson (staff), and both the Senate Health and Human Services committee staff as well as the House Human Services staff.

Let me begin by stating that I didn’t make any appointments with anyone ahead of time.  While this is courteous, I did not want anyone to have a chance to prepare.  I also, intentionally, came dressed as a parent of a child with special needs as opposed to a lobbyist.  So I showed up in khakis with a tie, but no expensive suits.  In each office, I walked in and announced that I am the parent of a child with Down Syndrome and I’d like to talk to someone about legislation and appropriations.

To start with my legislators, I spent a great deal more time with them and their staff than anyone else.  I focused my discussions with them around the following:

  • Senate Bill 7
  • State Supported Living Centers
  • Balancing Incentive funds

I think SB7 is going to pass.  So I had several talking points on this bill.  It has great intentions – more services to more people at reduced cost to the state.    Having said that, the devil is in the details and the people pushing the bill don’t understand the details, which is critical in this circumstance.  First, there needs to be significant stakeholder support at all stages.  That means as invited testimony (after all, the parents and family members – not the state agencies, are the experts on this topic), voting members of system redesign committees, and at each stage of legislation and rulemaking.  Second, there needs to be an understanding that this is an incredibly complicated population and service delivery driven by assessments is going to miss a lot.  I made the point that this population requires medical care, dental care, many types of therapies, 24/7 care, employment care, housing, etc.  To illustrate the complexity, I used an example from the state supported living centers.  Back when the Department of Justice issued its findings about the old state schools, it used two specific examples as examples of a lack of oversight by the schools.  In one example, a state school resident had been eating latex gloves.  In another, a different resident was eating the stuffing from a chair.  I used these examples and explained that they are examples of how profoundly some individuals with intellectual and developmental disabilities are affected and how difficult it’s going to be to assess this and come up with services to prevent it.  I made these SB7 point with everyone and every committee that I visited with, with two exceptions that I’ll talk about in a minute.  In each case, the people I talked to had no idea it was like this.

Regarding the state supported living centers, I focused on two things.  First, if we are going to have them we should do it right – which means strong funding and appropriate staffing for fewer of them.  Second, Sen. Rodriguez has filled two bills (one is SB 729) on evaluating the SSLC’s and establishing a realignment commission for them.  I wanted my legislators to know that I support both bills.

The Federal Government is making available ‘Balancing Incentive” (BIP) funds for Medicaid programs.  My understanding is that this is intended to be seed money to kick start efficiencies and better service delivery.  So, for example, the website I spoke about earlier is going to be funded by BIP funding.  The problem is that both the House and Senate appropriations committees are sweeping more programs into this funding (because the state doesn’t have to pay for it).  This is a problem because the funds will go away, so any on-going program will lose funding once that happens.  This happened two sessions ago with Federal stimulus funding and ECI – ECI was ramped up and expanded with that funding, but after it went away it had to be cut back because the state would not make up the difference.  This is a concern with BIP funding.

I visited with Rep. Carter’s staff.  She is on the House’s appropriation’s committee for Article II (health and human services).  I had written each of them about the need to fully fund ECI, which they did.  She wrote me back, so I visited to say thank you.  I also put in my $0.02 about the BIP funding that I mentioned above with her staff.

Rep. Raymond is the chair of the House Human Services committee.  His office will either craft its own version of SB7 or receive the Senate version once the Senate passes it.  I spoke with his staff about the points I described above.  After meeting with me, they asked me to go talk to the Human Services committee staff about this, which I did.  This (the committee meeting) was one of the longer meetings that I was in today.

As the author of SB 7, I dropped by Sen. Nelson’s office.  Her office made it clear that they are not the ones listening to feedback about this bill and that I should go speak with the Senate Health and Human Services committee staff (which is located in another building).  I did this, and they let me know that the only person qualified to listen to feedback isn’t available – but I’m welcome to email (which I will).  I think it’s evident that the good senator is no longer desiring to hear feedback about what she set in motion from normal people.

I appreciate the time that everyone (with one exception) gave me.  I think I was able to make the points about the need for significant stakeholder involvement combined with an appreciation for how complex these matters are, while everyone has great intentions there’s a real lack of understanding about the things they are trying to change.  I’m also very happy because I have lots of contacts, who will be receiving my thoughts on these matters as the session progresses!

The Texas Legislature has released their budget bills, House Bill 1 and Senate Bill 1.  When passed, these bills will be the funding for state agencies in 2014 and 2015.    This information is important because it has an impact on the various state agencies to provide services.

 

In the current biennium (2012/2013), the Department of Aging and Disability Services is receiving approximately $12.5 billion in funding for providing long-term services and supports to the aging, disabled, and individuals with intellectual and developmental disabilities.  For the upcoming biennium (2014/2015), DADS has asked for $13.5 billion (or an 8% increase).  Both HB1 and SB1 fall well short of DADS’ ask.  HB1 provides for $12.7 billion (or a 1.8% increase over the current biennium), SB1 provides for $12.59 billion, or a .6% increase over the current biennium.

 

There are a number of programs that are seeing reductions in HB1 and SB1.  These include:

  • Primary home care (~50% reduction): Provides non-skilled personal care services.  Reduction is due to STAR+PLUS and this service will eventually be eliminated.
  • Day Activity and Health Services (~67% reduction): Another casualty to STAR+PLUS.
  • Community-Based Alternatives (~24% reduction): due to STAR+PLUS.
  • ID Community Services (~7% reduction): Administrative expenses are being transferred elsewhere and some of the individuals receiving services are being transferred to the Texas Home Living Waiver.
  • Promoting Independence Services (~5% reduction): Another casualty due to STAR+PLUS.
  • State Supported Living Centers (~3% reduction)

 

There are also a number of programs that are seeing increases in HB1 and SB1, these include:

  • Community Attendant Services (11% in HB1, 6% in SB1): Seems to be balancing out the reduction in primary home care.
  • Home Community-Based Services (HCS) (7% increase)
  • Medically Dependent Children (4.6% increase)
  • Nursing Facility Payments (3.4% in HB1, 2.2% increase in SB1)
  • Medicare Skilled Nursing Facility (14% in HB1, 8.7% in SB1)
  • Hospice (7.4% in HB1, 5.5% in SB1)
  • Balancing Incentive Program (140% in both bills)

 

Basically these recommendations reflect a shift to providing services via managed care (see Senate Bill 57 for an example of what this could look like).  For some populations, this may be a good thing.  For individuals with intellectual and developmental disabilities, this may or may not be helpful.  There are several concerns with this.  First, managed care is using a medical model to treat diseases and apportion services accordingly.  People with IDD’s don’t have a medical condition that needs treated, so it’s difficult to fit their long term needs into a managed care setting.  Second, managed care organizations may not have experience with the IDD population, which may profoundly impact services.  Third, it’s unclear if managed care can quickly react to changing situations with people with IDD and provide the fast, flexible services that they sometimes need.

 

While both HB1 and SB1 provide an increase in funding (which is a positive), they do not come near to addressing the needs to the aging and disabled in Texas.  Now, neither budget bill is set in stone.  There will be lots of opportunities for input.  First, you can contact your representative and senator and provide feedback.  Second, there will be plenty of budget hearings over the next few months where written testimony and in-person testimony can be provided.  The budgets will go through a cycle of hearings, adjustments, and both the Senate and House versions will need to be reconciled before it goes to the Governor for his signature.

 

The Texas Legislature has released their budget bills, House Bill 1 and Senate Bill 1.  When passed, these bills will be the funding for state agencies in 2014 and 2015.    This information is important because it has an impact on the various state agencies to provide services.

The proposed budget for Early Childhood Intervention, administrated by the Department of Assistive and Rehabilitative Services, is mixed.  In the current biennium, ECI will receive $274,144,828 to provide services, provide respite services, and ensure the quality of ECI statewide.  This current biennium represented a sharp decrease in funding compared to the previous one.  As a result, DARS had to implement a number of changes to help contain costs while continuing to provide services.

These changes included implementing a family cost share.  In other words, families paid for a portion of their child’s ECI services according to a sliding scale based upon family income (families with more income paid more).  Another change was to require ECI providers to directly bill Medicaid to be reimbursed.  This saved DARS money because it meant that DARS no longer had to do this.  However, this was a skill set that many providers did not have and has led to challenging decisions such as: Do I hire a provider or someone knowledgeable about Medicaid billing?  Finally, DARS narrowed the criteria of who is eligible for ECI services, which meant that fewer children are receiving services today.

Now, this last change especially has had some ramifications.  By narrowing the eligibility, the make-up of the children receiving ECI services has changed.  This has resulted in their being more severely impacted by delays, requiring more services, increasing the cost of those services.   As a result, DARS is projecting that if funding for ECI remains flat over the 2014/2015 biennium, they will have to narrow eligibility even further.

In the current biennium, DARS is receiving approximately $274 million for ECI.  They asked for approximately $334 million, which took into account the state’s population increases, projected future demand, and the change in the make-up of children receiving those services.  Both HB1 and SB1 are recommending that ECI receive $297 million in funding, which represents an 8.5% increase over the current biennium.

While the increase in funding is a positive thing, it does come close to what DARS needs to continue offering services at the current eligibility level.  It is likely that if the budget passes as is, that DARS will have to narrow the eligibility in the upcoming biennium.

Now, neither budget bill is set in stone.  There will be lots of opportunities for input.  First, you can contact your representative and senator and provide feedback.  Second, there will be plenty of budget hearings over the next few months where written testimony and in-person testimony can be provided.  The budgets will go through a cycle of hearings, adjustments, and both the Senate and House versions will need to be reconciled before it goes to the Governor for his signature.

Today I attended the Children’s Policy Council meeting in Austin. During the last part of that meeting, we had a briefing on how to approach the Texas Legislature from the standpoint of influencing legislation and funding. What follows are several principles for working with the Legislature.

I should point out ahead of time that this advice largely deals with advocacy groups and lobbyists. At the end of this blog I’ll have some thoughts on doing this as an individual.

The principles are:
• Some of the messages have been out there for awhile. This is important because it means that you don’t have to reinvent the wheel. If someone else has attempted to advance legislation of funding similar to what you are trying to get done in previous sessions, then that legislator can be approached. Just because it didn’t pass in the past doesn’t mean that it might not pass now.
• Other people may be working on this same issue. This includes other organizations, state agencies, and even other legislators. If that’s the case this becomes easier because you are not having to start from scratch and it’s more likely to get done with many parties interested in it.
• What are the greatest priorities? Two thoughts with this. First, it’s important sometimes to take baby steps as these are more likely to get done than the massive, sweeping reform that everyone wants. While this falls short of the ultimate mark, it allows everyone to be successful and gradually gets us where we want to go. Second, sometimes it’s okay to shoot for the moon and suffer a noble failure. The attempt gets attention and might result in good looking at the long term.
• Legislation gives things a priority and helps nudge it into happening. Not everything requires legislation, but sometimes it helps to make things important to state agencies and increases the likelihood that it will happen.
• Companion bills are essential. Legislation is more likely to be successful if a similar bill is filed in both the House and the Senate.
• You need champions. This means you need someone, or several someones, to support and move the intended legislation. Some thoughts to keep in mind with this:
o Who has expressed an interest in your agenda? These are your friends and are more likely to help advance your interests.
o Relationships with members and staff matter. Which staff members do you have good relationships with? Even if they can’t get the legislation advanced by their legislator, at least they can give you honest feedback.
o Have members had legislation on this topic in the past? If so, use them.
o Look at committee chairs and committee membership, also who has historical experience with committees. These individuals are more likely to be able to get things done.
o Get both parties involved. Bi-partisan support makes it a lot more likely for things to get through the Legislature.
o Who is the opposition? Why are they opposed? Can they be worked with? Sometimes it’s a state agency… Even if there’s opposition, sometimes you still must proceed.

All of the above requires doing a great deal of homework, but that’s essential if you are seeking to effect change.

Now, the above steps apply to an organization – like a not-for-profit. This becomes a lot more difficult for an individual, but I think sometimes the individual is more important. You can see not-for-profits and advocacy groups being tuned out by staffers and legislators, whereas the individual constituent might be able to make an impact. If an individual wants to do this, here are some suggestions:
• Legislators and their staffers know who their constituents are. If you are not one of them, you will not influence them. If you are one, meet with them and/or their staff in person, especially when they are in their home office and be professional.
• Your legislator may not have your issue as one of his/her “pet” issues. If you are interested in medical services for disabled children, but your legislator’s issue is highway construction, then he/she may not be able to effectively advance your interests. But your legislator knows other legislators…
• You still have to prioritize. Failing to do this results in you asking for things that are not possible, which tends to get you ignored.
• Don’t assume knowledge on the part of your legislator, you may need to educate. There’s a way to do this and there’s a way to appear arrogant. This goes back to being professional.
• Policy makers love numbers. Do your homework. You provide a face to the issue and provide a real, emotional, human story. But ultimately numbers sell the issue and you need to have everything.
• Don’t be afraid to testify. Testify in writing if you cannot make it to the hearing. Go to the hearing if you can, testimony from parents is powerful and a lot more likely to influence things – especially if you know your topic, speak clearly, and keep it professional.

Election day is coming up next week (November 6, 2012). After that, the members of the Texas Legislature will begin pre-filing bills. By January there will be hundreds of bills, so it’s more likely that bills will get lost in the traffic. By March there will be thousands of bills. So it’s important to get on top of this early.

Yesterday I participated in the Children’s Policy Council’s briefing for the Texas legislature.  The Children’s Policy Council (CPC) was established by the 2001 Legislature to help provide recommendations to the state about integrating services to children with special needs to provide the services that are needed in a more effective, cost-effective, and integrated way.   It’s membership is primarily parents of children with special needs, which allows it to provide a unique perspective to the state.  Every even-numbered year, the CPC produces a report with recommendations for the Legislature.  The 2012 report can be found here: http://www.hhsc.state.tx.us/si/C-LTC/2012-CPC-Leg-Report.pdf .

 

The CPC conducted a briefing based upon the recommendations found in the report to the Legislature and state agency employees in the state capital yesterday.   I’m happy to report that staffers from about 25 representatives and senators attended as well as staffers from the Department of Assistive and Rehabilitative Services, the Department of Aging and Disability Services, and the Health and Human Services Commission.

 

I discussed the need to fully fund Early Childhood Intervention (ECI).  I have covered a lot of the issues elsewhere (see: http://wp.me/pZf7K-7F for the most recent summary), but none of the CPC assumed knowledge on the part of the people attending the briefing.  I began by discussing what ECI is and what it does.  I explained that there is a narrow window (birth to age three) when services can be provided to children that might be less expensive and easier due to the fact that children are developing rapidly at this age.  Failing to address delays at this age doesn’t make them go away, it makes them someone else’s problem (the school districts and society’s) which becomes more difficult and more expensive as the child ages.

 

After that I covered the history.  Namely that the funding for ECI has been cut for several years.  In fiscal year 2010 it was 197 million dollars.  In FY2012 it was 163 million dollars.  In FY2014, DARS is asking for 145 million with an additional 40 million in exceptional items.  The result of this has had an impact on how many children receive services as well as who those children are.  As I have written about elsewhere, I explained the consequences of the Legislature’s short-sightedness with ECI and explained why it needs to be fully funded.

 

With one exception, all of the other presenters at this briefing were parents.  This was powerful as it provided a human face to the services and programs that the CPC is recommending.  One of the parents, Cheryl Fries, began her presentation by talking about her “D Day,” the day her family received the diagnosis of their child’s disability.  She told those attending the briefing that each parent of a special needs child has their D Day burned into their memory and that none of us asked to be part of this club, but we’re all members nonetheless.  I thought that was a powerful statement and I’m going to borrow that in the future.

 

The one exception was Dr. Carl Tapia, who is a pediatrician specializing in children with special needs.  He discussed the CPC’s recommendations for reforming acute Medicaid services.  The CPC has been involved in making recommendations to the state about redesigning both long term services and supports as well as acute Medicaid services.

 

I found the briefing to be a positive experience.  We had a good turnout and I felt that they were attentive and asked questions.  Now how things play out during the upcoming session is anyone’s guess…

Yesterday (10/10/12) I attended the Early Childhood Intervention (ECI) Advisory Committee quarterly meeting. There were several interesting items that came up in the meeting:
• Report on family outcomes
• Consequences to the system changed to ECI in Texas
• Providers of ECI in Texas

Family Outcomes
The Department of Assistive and Rehabilitative Services (DARS) ECI staff does an annual report to the federal Office of Special Education Programs. Among other things, ECI reports on three family outcome indicators:
1. How helpful has ECI been on helping families know their rights?
2. How helpful has ECI been for communicating their child’s needs?
3. How helpful has ECI been in helping the child to develop and learn?

Each indicator is made up of 6-8 questions. These indicators are measured via a survey that is conducted amongst half of the ECI providers in December.

For the fiscal year that just ended (FY2012), the three indicators declined relative to the year before, though they all met the targets that the state has set. Drilling down into the indicators, it appears that three concerns were responsible for this decline:
• Transition education from ECI to the next stage
• Education about the range of services available to the family and the child
• Helping children get along with others: in terms of behavior but also in terms of things like day care placement

There are two cautions about this survey and its results. First, the timing is important. This survey went out just as the system-wide changes to ECI were really beginning to kick in. It’s unclear our reflective these survey results are of the situation today, a year after the system-wide changes were implemented. Second, the sample size is incredibly small. These survey results are based on 943 responses. In December of 2011 there were 25,035 children enrolled in ECI. With the survey going out to half the programs, there are somewhere around 12,517 potential children in that population (although that is dependent on the size of the programs surveyed). 943 out of 12,517 represent a sample size of 7.5%. Here’s the problem: a sample size that is too small means you are unsure if the survey results adequately reflect the population. Normally when conducting surveys you figure out what type of sample size you need. When I asked about this, I got a deflecting-type of answer.

Consequences of System Changes
The system-wide changes to ECI (narrowing of eligibility, family cost share, provider direct billing of Medicaid, and measureable outcomes) have had effects on providers, families, and children. For the providers, they have been in an identity crisis and have had to gradually shift their focus away from families and more towards business, billing, and measuring/assessing outcomes.

For everyone else, the consequences of the system-wide changes have been complicated. First, by narrowing eligibility fewer children are being served. In FY2010 there were 32,101 children being served. In FY2012, there were 25,035. This is a 22% reduction. Second, by narrowing eligibility the mix of who is receiving ECI has changed. In 2010, 16% of those children were “atypical” in the sense that they were not developing at the “normal” rate. Today that group makes up 3% of the ECI population whereas there are a greater percentage of children with a medical diagnosis or developmental delays. This means that those individuals still receiving services require more intensive services. As a result, the average direct services per child per month has increased from 2.1 hours in FY2010 to 2.7 hours in FY2012 (a 29% increase). It is expected to eventually move up to 2.9. On the surface this sounds positive, but as the population of Texas increases and if funding stays static, it means that fewer children will be able to be served in future years.

Providers of ECI
Since FY2010, the number of ECI providers in Texas has declined from 58 to 51, or a 12% reduction. Of the seven providers that were lost, 3 were independent school districts and 2 were education service centers. In other words, 5/7 of the providers lost were related to the public school system. This is largely because as providing ECI has become more complicated in terms of narrowed eligibility, direct billing of Medicaid, and outcomes assessment the public school system is deciding that this is too difficult given that working with 0-3 year olds isn’t part of their purpose for being here.

Below is a copy of my written testimony for Texas’ Department of Aging and Disability Services’ Legislative Appropriations Request hearing, which is scheduled for September 11, 2012. The full document of the LAR is located here: http://cfoweb.dads.state.tx.us/lar/default.asp and this represents the first round of hearings for what will be the department’s 2014 and 2015 budgets:

I want to thank the Legislative Budget Board and the Legislature for the opportunity to comment on the Legislative Appropriations Request (LAR) for the Department of Aging and Disability Services (DADS). I am the parent of a five year old with Down’s Syndrome who will one day be an adult with Down’s Syndrome, so I am very interested in the services offered by the state of Texas. In addition to being a parent, I also serve as an appointed parent representative on the Children’s Policy Council, the Task Force for Children with Special Needs, and the Early Childhood Intervention Committee. In this letter, I’d like to ask the LBB and the Legislature to consider several items that were in DADS’ LAR as well as several items that were not.

With regards to items that were in the LAR:
• This LAR reflects a shift over to managed care. It is also reflecting the fact that whether we like it or not, costs increase and this must be accounted for via appropriations. If it is not, then the only way to balance things out is to reduce services. DADS is attempting to do this via two of their special items; maintaining caseloads and cost trends. These items represent approximately $101 million in FY14. If these special items are not funded then DADS will have to reduce services to Texans.
• If the state of Texas is committed to maintaining the State Supported Living Center (SSLC) system, then funds must be made available to keep them modern and well-staffed so that they are able to provide the best services possible to the residents. With that in mind, then the special item dealing with this (approximately $112 million in FY14) must be funded.
• It is in the best interests of Texas, and the individuals affected, to have people move from residential facilities to the community. In the community there are fewer risks of abuse, better opportunities for work, and an ability for people to thrive. Two of the special items (promoting independence and community expansion) that total approximately $151 million in FY14 deal with this and should be funded.

There were several items that were not in the LAR that I’d like to ask the LBB and the Legislature to consider:
• 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.
• 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 to include a rider in the general appropriates bill directing DADS to close at least one SSLC; to include a rider requiring DADS to submit a closure plan; to include a rider to authorize DADS to reclassify one FTE position to direct the closure process; and to amend the Health and Safety Code to establish a realignment/closure commission (for SSLCs). These recommendations did not go anywhere in 2011. DADS and the LBB need to provide leadership on this matter and resubmit these recommendations to the Legislature in order to give DADS the flexibility to modernize its services in this area. The fact of the matter is that the SSLCs are not sustainable and the most fundamental issue with them is the fact that there simply is not enough money to hire and retain the caliber of front-line staff, keep the facilities and services modern, and provide the residents the opportunity to thrive.

• 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.

Thank you again for the opportunity to comment on this important matter. Thank you for your service in these difficult times.

The Legislative Appropriations Request (LAR) for the Department of Aging and Disability Services (DADS) in Texas has been published.  The full document can be found here: http://cfoweb.dads.state.tx.us/lar/default.asp.  In Texas, the way the budget process works is that it is done by biennium (this is because the Legislature meets every two years).  So, during the summer of the even-numbered years the various agencies submit their LAR.  This is what they want their budgets to be given instructions and limitations provided by the state’s leadership.  This goes to a hearing before representatives of the Governor’s office, the Legislature, and the Legislative Budget Board (LBB).  The LBB then makes recommendations based upon this to the Legislature, who prepares and votes for the budget which the Governor then signs (or vetoes).  The actual budget that the agency receives for the biennium may or may not reflect what they submit via their LAR.

 

The current biennium is FY2012 (the current year, which ends August 31) and FY2013.  The LAR that has been submitted will cover FY2014 and FY2015.  So in this blog I’ll compare FY2012 to FY2014.  I’m only going to focus this post on DADS’ goal of providing long-term services and supports.  I won’t post anything about their regulation/outreach and indirect administration goals.  The long-term services and support goal has several objectives and supporting strategies.  These include intake/access, waivers, entitlements, community services, nursing facility payments, promoting independence, ICF’s, and state supported living centers.

 

The current fiscal year (2012) has approximately $6.4 billion budgeted for these.  DADS is requesting $6.15 billion for fiscal year 2014 (the first year of this LAR), a 3.5% decrease.  Much of this is due to the roll out of STAR+PLUS and services being absorbed by STAR+PLUS.  This decrease is primarily coming from the following areas:

  • Primary home care: this is the providing of non-skilled personal care services.  This is seeing a major reduction (FY12 to FY14) due to STAR+PLUS, which will eventually see this strategy be eliminated.
  • Day activity and health services:  This refers to adult day care services and is another being impacted (and eventually eliminated) by STAR+PLUS.
  • Community based alternatives: This is a service designed to help keep people out of facilities, it’s another that is impacted by STAR+PLUS and will eventually be eliminated.
  • ID community services: The intellectual disability services are seeing a reduction of approximately 14% comparing FY2012 to FY2014.  This is due to the administrative expenses being transferred elsewhere and to some of the individuals receiving services being transferred to the Texas Home Living Waiver (see below).
  • Promoting independence by providing community-based services: This service is designed to help get people out of residential facilities and back into the community.  It is seeing a reduction due to STAR+PLUS.
  • State supported living centers: The state supported living centers are seeing a strange funding pattern.  From FY2012 to FY2013, they are losing 1.3% of their funding.  From FY2013 to FY2014, they will see a 0.6% increase in funding, partially restoring some of what was lost. 

 

The following areas are actually seeing an increase in this LAR:

  • Community attendant services: This increase seems to be balancing out the reduction in primary home care.
  • Home and community-based services (HCS Waiver): Compared to 2012 HCS is seeing a large increase in funding (roughly 4%).  But this is fairly flat compared to FY2013’s funding.
  • Texas Home Living Waiver: Compared to 2012 this is seeing a large increase in funding (roughly 41%), but this is flat compared to FY2013’s funding.  This increase over FY2013 represents instructions from the current appropriation’s act to provide services to more individuals via this waiver.
  • ICF’s: Intermediate care facilities for an individual with an intellectual disability are seeing an approximately 1.3% increase in funding from FY2012 to FY2014. 

 

Now, DADS also has eight exceptional items which will impact many of the areas highlighted above.  The amounts shown reflect all funding sources for FY2014 only:

  • Maintain caseloads: approximately $11.4 million.  The instructions that DADS received on this LAR were essentially no new growth in their baseline request.  If that is done, by 2014 they will not be able to maintain 2013’s caseload levels – which means reducing the number of people serviced.  This exceptional item is meant to keep that from happening.
  • Cost trends: approximately $90 million.  DADS was instructed to show cost increases, rate increases, etc. as exceptional items.  DADS points out that they have no ability to control these cost increases and failing to fund this will reduce services.
  • Promoting independence: approximately $20 million.  This exceptional item is meant to get a number of individuals out of residential centers and to provide crisis services to individuals in immediate risk of institutionalization.
  • Community expansion: approximately $131 million.  This item would increase community services for individuals on interest lists.  For example, it would serve 20% of the eligible individuals on HCS and CLASS interest lists.
  • Protecting vulnerable Texans: approximately $12 million.  This would add staff and help upgrade IT systems in areas like guardianship, ombudsmen, adult protective services, etc.
  • Improving support for SSLC residents: approximately $112 million.  These are infrastructure improvements to the state supported living centers.  Things like furniture, computers, IT upgrades, vehicles, repairs/renovations, etc.
  • Streamlining service systems: approximately $9 million.  This is primarily an information technology initiative.
  • PACE expansion: $1 million.  This would add additional PACE slots and fund new sites.

 

All of these exceptional items total about $385 million for FY2014, of that $258 million would be from Federal funds or other funds, only $127 million from the state.  In FY2015, these exceptional items would expand to over a billion dollars.  This is primarily from the following:

  • Cost trends: expands to $195 million
  • Promoting independence: expands to $60 million
  • Community expansion: expands to $765 million
  • PACE expansion: expands to almost $11 million

 

Of this billion dollars, $337 million would be from the state with the rest from Federal and other funds.

 

How will this LAR potentially impact Texans with disabilities?  First, it demonstrates that Medicaid recipients are going to be rolled into managed care, which has pro’s and con’s.  Second, it’s renewing the commitment to the state supported living centers and the ICF’s.  Third, there is never going to be enough money to fund the number of waiver slots needed, combined with the increase in costs.  Finally, in my opinion the exceptional items should be called “Things We Need  To Do Just To Hang On,” if they are viewed as superfluous by the state’s decision makers then this will end up hurting the elderly and disabled in Texas.

The Department of Assistive and Rehabilitative Services (DARS) in Texas published its Legislative Appropriations Request (LAR) on its website yesterday.  To view this document in its entirety click here:   .  This is where the agency makes its request to the Legislature, Governor, and Legislative Budget Board for its funding for 2014 and 2015.  This will be followed by a hearing before those bodies on September 10, 2012 in Austin where DARS will present this request.  I’m going to write a little bit about the background behind this request, the consequences of the background, and discuss how the current request impacts Early Childhood Intervention (ECI).

First, as background ECI had its funding cut by 14% for 2012 and 2013 (the current biennium).  As a result, DARS had to make some tough decisions to continue to offer services with such a reduced budget.  These decisions were:

  1. Narrow the eligibility requirements of who gets ECI services.  This means that fewer kids are receiving services today.
  2. Implement a family cost share, which means that as a family’s income level increases they pay for a greater share of the ECI services that their child receives.
  3. Require ECI providers to directly bill Medicaid to be reimbursed.  This is was not a skill set that many of these providers possessed.

The effect of these cuts has been dramatic.  In 2011, 3.62% of children under the age of three were served by ECI.  This number will drop to 2.96% in 2014.  In 2011, the number of children enrolled in ECI declined by 6.1%.  This will decline by a further 17.1% in 2012 and is forecasted to be flat (i.e. zero growth) in 2014.  The DARS LAR has ECI services suffering a 12% reduction in funding from 2011 to 2014. 

There are a number of complications.  First, the population of Texas is increasing.  Just because of this the number of children needing ECI services will increase.  Second, while narrowing the eligibility decreased the number of children receiving ECI it also had another effect, it meant that those children receiving ECI were more significantly delayed and required more services.  The combination of these two mean that keeping funding flat (i.e. the proposed LAR) will result in another narrowing of eligibility because the current funds cannot fund the future demands even with the changes that have been put into place.

As a result of this, DARS has two exceptional items that they are requesting funding for with regards to ECI.  The first requests approximately $8 million in 2014 and $16.5 million from all funds to fund the anticipated growth in the number of children who will qualify for ECI even under the current narrowed eligibility criteria.  The second requests approximately $8.7 million in 2014 and $9.2 million in 2015 to maintain the level of service to children (this refers to hours/week) due to the fact that children with more severe delays (which is the result of narrowed eligibility criteria) require more services.

If ECI does not receive the exceptional item funding that it is requesting, then it will have to narrow the eligibility requirements still further. This will mean that fewer children with needs will receive services.  These needs won’t go away, they will be transferred to the public schools because they are not addressed early.  This may impact children’s success in school, their success in employment, and the amount of public assistance they are going to require in school and in their post-school lives.