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Tag Archives: DARS

Over the past few months, the Texas Sunset Commission has issued reports and recommendations about each of the agencies under the Health and Human Services umbrella. For example, here’s a write up I did about their recommendations for the state supported living centers: http://wp.me/pZf7K-9t and here’s one for the Department of Aging and Disability Services: http://wp.me/pZf7K-9p /

The Texas Sunset Commission has completed its review and recommendations for the Texas Health and Human Services Commission (HHSC). The full report can be found here: https://www.sunset.texas.gov/public/uploads/files/reports/HHSC%20and%20System%20Staff%20Report.pdf . The Sunset Commission issued 15 recommendations pertaining to HHSC, only a few of which will I discuss in detail:
• Health and Human Services agencies should be consolidated
• Medicaid can be administered better
• Participation in Medicaid by providers is being discouraged
• There is a need to improve quality of health care
• There are too many advisory committees

Consolidation:
The Health and Human Services system has expenditures of almost $35 billion annually with 54,000 employees. This is spread out across five agencies. It is the Sunset Commission’s opinion in their report that the size and scope of the five agencies creates blurred accountability, fragmentation of programs and services, “organizational misalignment,” ineffective regulatory services, and some real challenges with the current organizational structure of the enterprise. For example, the report mentions that the Department of State Health services has a focus that is too broad, the existence of the Department of Aging and Disability Services is questionable after Senate Bill 7 (managed care), and the Department of Assistive and Rehabilitative Services has too narrow of a focus and some of its programs and services are duplicated by DADS.

As a result of the above, the Sunset Commission recommends:
• All the agencies be consolidated into one.
• Organize the new entity along functional lines:
o Central/support services (i.e. administrative support)
o Medical and social services
o State institutions and facilities
o Family and protective services
o Public health services
o Regulatory services
o Office of inspector general
• Establish a policy and performance office

Medicaid can be administered better:
The Sunset Commission found the Medicaid is fragmented because it is administered by DADS, DSHS, and HHSC. This leads to a lack of communication, a lack of policies and program administration, duplication, and inefficient delivery of services. The recommendation is to consolidate all the Medicaid programs (waivers, entitlement programs, YES waiver, etc.) to HHSC, which falls in line with the consolidation recommendation above.

Participation in Medicaid by providers is being discouraged:
According to the Sunset report, only 31% of physicians are willing to accept new Medicaid clients. The report finds that it is too difficult to enroll (it may take three to twelve months to navigate the state’s system and become enrolled as a provider), there are huge administrative burdens on the part of providers, and the reimbursement rates are low. As a result, the Sunset Commission is recommending that HHSC streamline and centralize the provider enrollment process, streamline the criminal history process and require a fast (10 day) turnaround.

Health care quality:
According to the Sunset report, there are 270 different initiatives to improve the quality and outcomes of Health and Human Services programs and services! This creates a lack of focus, administrative burdens, inefficiencies, and missed opportunities. The Sunset Commission recommends that HHSC develop a comprehensive, coordinated plan to ensure consistent approaches for improving the quality of health care and require HHSC to pilot incentive-based payments by managed care organizations.

Advisory committees:
HHSC has 41 advisory committees. In 2013 this amounted to 189 meetings, 16,700 staff hours, and cost the state $800,000. Most of these committees are established by legislation and have reporting requirements, which adds to HHSC’s administrative burden. There are six managed care advisory committees, four committees dealing with children, five committees dealing with quality matters, etc. Needless to say, there is a lot of duplication with questionable effectiveness. As a disclaimer, I’ve served on two of the children’s committees.

The Sunset Commission recommends that the advisory committees be removed from statutes, allowing HHSC to establish by rule those that are necessary. It recommends combining the four children’s committees into one. It also recommends that HHSC create a master committee calendar, meetings be streamed, and that meeting materials be accessible online.

I’ve only covered five of the recommendations, the Sunset Commission made 15 for HHSC. As you can see from this, though, the recommendations are huge in scope and needed. From here, it gets mired in politics. I have a feeling this is going to be the issue for the Legislature this spring. It is worth reading these reports and contacting your legislators and letting them know if you support these recommendations or not.

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The Texas Department of Assistive and Rehabilitative Services (DARS) has released their Legislative Appropriations Request (LAR). The full document can be found here: http://www.dars.state.tx.us/reports/lar2016_2017.pdf . This document represents the agency’s budget request for fiscal years 2016 and 2017 (taken together these are a biennium). This is the first step in the budget process, where the agency identifies what it needs and what special requests that it has. This will be matched in the beginning of the Legislative session in the spring of 2015 with a document by the Legislative Budget Board, which will be their view of what the agency needs. The agency will then spend the spring testifying before the Texas Legislature to secure its appropriations.

This is an extremely important document because there may very well be more significant changes on the horizon for the Early Childhood Intervention (ECI) program. Reading through the document, DARS tells us that in fiscal year (FY) 2013, ECI served approximately 25,000 children per month. In their LAR, they are projecting to serve a little over 22,800 by FY2017. This represents an almost 9 percent decrease. During this time, the average monthly number of hours of service per child per month is projected to increase from 2.61 hours/month to 2.93.

In their LAR, DARS is projecting that ECI will essentially maintain its budget in FY 2016, but will see a reduction of more than 15% during FY2017. In other words, in their baseline budget request DARS is telling us that they are projecting a decrease in funding and are projecting that they will need to serve fewer Texans between the ages of birth and three years old.

As a result of this, DARS is making two special requests for funding in their LAR on behalf of the ECI program. The first is a request of over $25,000,000 over the biennium just to maintain the projected FY2015 case levels. From page 189 of the LAR: “Federal IDEA Part C funding available to fund the ECI system in Texas has remained flat in recent history. However, ECI program costs associated with federal
requirements and not reimbursed by Medicaid has resulted in the agency using more federal IDEA Part C funding for allowable program expenses than projected. As DARS uses more IDEA Part C funding in fiscal years 2014-2016 to support ECI program costs, the result is less IDEA Part C funding available to maintain base funding levels and serve eligible children in fiscal year 2017. Funding for this exceptional item is to maintain the number of children served in fiscal year 2016 in fiscal year 2017 in the ECI
program.”

What does this mean? It means that Texas has consistently underfunded the ECI program, relying on a finite amount of Federal funding instead. That funding is running out, creating a shortfall. If that shortfall is not covered, Texas will have to provide ECI services to fewer children.

The second special request is an additional $25,000,000 over the biennium to increase monthly caseload to over 30,000 by FY2017. DARS is projecting that even with their more stringent eligibility criteria the number of young Texans who qualify for ECI is going to increase pretty dramatically by FY17.

My take on the bottom line, DARS needs an almost fifty million additional dollars over the biennium to continue to offer services to young Texans who qualify under the current eligibility criteria. If they can’t get that through the Legislature, there will be another difficult round of system changes that involve a combination of more stringent eligibility criteria (so fewer children are being served) combined with more family cost share.

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.

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.

In previous postings I have discussed issues that have arisen as a result of funding constraints for Early Childhood Intervention (ECI) in Texas.  As a result of funding constraints, the state agency that oversees ECI (Department of Assistive and Rehabilitative Services, DARS) had to make changes to ECI which included:

  • Narrowing the eligibility of who qualifies for ECI
  • Implementing a family cost share so that parents pay for some of the services
  • Requiring ECI providers to directly bill Medicaid for reimbursement

 

These changes had unintended consequences.  Because eligibility was narrowed, it resulted in the children being admitted to the program needing greater services.  This means that ultimately as the population increases, the program will have to be narrowed even further (if funding remains static) due to this.

 

Texas is not the only state experiencing challenges with providing ECI to children and infants.  The IDEA Infant and Toddler Coordinators Association (www.ideainfanttoddler.org) does an annual survey of IDEA Part C (i.e. ECI) coordinators about implementation issues and challenges.   The 2011 survey is located here: www.ideainfanttoddler.org/pdf/2011_State_Challenges.pdf .  The survey results are sobering.

 

I’ll look at this report dealing with several matters:

  • Eligibility for ECI
  • Service delivery
  • Fiscal matters
  • Participation in Part C

 

Eligibility:

Texas narrowed the eligibility of infants and toddlers who qualify for ECI, as a result fewer children are admitted into ECI.  Of the 50 states and 3 territories surveyed:

  • 20 states require one of the following for eligibility for ECI: at least 25% delayed in two or more domains, 30% delay in one or more domains, 33% delay in one domain, 1.3 standard deviations in two domains, 1.5 standard deviations in one domain
  • 18 states require one of the following for eligibility for ECI: 40% delay in one domain, 50% delay in one domain, 1.5 standard deviations in two or more domains, 1.75 standard deviations in one domain, 2 standard deviations in one domain, 2 standard deviations in two or more domains.

 

In other words, 38 states are more restrictive than Texas in terms of eligibility criteria.  In addition, ten states made their eligibility criteria more restrictive over the last three years.  One made theirs broader.  Ten are changing their criteria this year.

 

Service Delivery:

Looking at all states, the number of direct services hours that were delivered, per child per month, has declined by approximately 22% from 2009 to 2011.  In 2011, the nationwide median for number of hours of delivered services, per child, per month, was 4.5 hours.

 

Fiscal Matters:

As a result of funding challenges:

  • 8 states have implemented family cost shares or increased those fees
  • 9 states have required the use of private insurance for ECI
  • 9 states have narrowed eligibility
  • 8 states have required prior approval when service hours exceed a specific amount
  • 13 states have reduced ECI provider reimbursement

 

21 states have conducted some type of study or planning process as a result of the fiscal situation.

 

In other words, like Texas, a lot of states are experiencing funding challenges with ECI.

 

Participation in Part C:

Worryingly, according to this survey, eight states are discussing or planning dropping out of Part C.  Most of this is due to the cost of the program and population growth (i.e. it’s not a sustainable program).

 

It’s a sobering look at the rest of the country and hopefully provides some perspective on what is happening in Texas currently.

 

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.

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.

Thank you for the opportunity to provide input on DARS’ 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 DARS can provide leadership via this LAR:

  • Sustainability and ECI
  • Access to services
  • Integration of planning
  • Senate Bill Seven
  • Stakeholder Input

Sustainability and ECI:

Thanks to a combination in loss of Federal stimulus funds as well as budget reductions from the 2011 Legislature, ECI has had to make some significant changes including implementing a family cost share, making eligibility to services more stringent, and having contractors directly bill Medicaid.  These are all band aid solutions that allowed ECI to survive the current challenges.  They do not take advantage of the opportunity the current climate represents to rethink ECI and how it can be both effective and sustainable in the future.  DARS, through this LAR, can at least educate the state’s decision makers about the importance of doing this.

 

Access to Services:

In the most recent draft of DARS’ strategic plan (shared with the ECI Advisory Committee during its April 11, 2012 meeting) it is evident that the need for services is significantly larger than DARS’ ability to meet that demand.  It is likely that the Legislature does not understand the scope of this disparity.  Again, the LAR can be a tool that DARS can u se to educate the Legislature.  While it probably won’t reverse the funding trend, at least the Legislature will be making a highly informed decision.

 

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 its enterprises.  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.

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

Stakeholder Input:

I appreciate DARS 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 DARS to continue soliciting stakeholder input at the beginning and during the planning process, rather than just with the final product.

Thank you again for the opportunity to provide feedback to DARS’ 2014-2015 LAR.  If you have any questions I may be reached at:

jcissik@yahoo.com

214-334-4754

Respectfully;

John M. Cissik

I was at the Early Childhood Intervention Advisory Committee meeting yesterday. A lot of the focus for the committee is going to be on writing next year’s annual performance report (APR), which I’ll talk more about later. The rest of the meeting was divided between the changes that are ongoing with ECI in Texas currently and also with a federal survey that was performed.

Changes to ECI:

Changes to ECI have been happening because state funding has been reduced and this is likely to get worse. This will be complicated by a future reduction in Federal funding (i.e. Medicaid) when the debt reduction efforts get serious. As a result, other ways have to be found to financially support ECI (after all, providers aren’t providing ECI services completely out of the goodness of their hearts – it’s a business for them and people want to be paid). The major changes are family cost share and having the ECI providers bill insurance and managed care for the services (see http://wp.me/pZf7K-4V for a summary of these changes). These changes have some interesting and immediate ripple effects. First, ECI providers now have to decide between hiring therapists and hiring billing specialists. In other words, they are sometimes having to enhance their administrative support at the expense of service providers (and this has to happen to get reimbursed for services). Second, this has the potential of making people less likely to take advantage of ECI services which could have long-term implications for their children.

It is likely that in the future state funding is going to continue to be reduced to ECI programs. It is also likely that federal funds will dry up as well as part of debt reduction. This is going to have a number of effects. First, state and federal dollars will probably end up being prioritized to those populations least able to afford the services. In other words, ECI will become an indigent program. Second, ECI providers will see declining profit margins resulting in fewer (and larger) programs that can take advantage of economies of scale. This has pros and cons. Third, ECI providers will increasingly need to rely on managed care and family cost share to service those populations not covered by state/federal funds. This has the potential to have more people focus on private therapy or to have more people simply not use the services.

Federal Survey:

The Feds had a third party put out an online survey about ECI to parents. Part of yesterday’s meeting was devoted to covering the results of the survey. The survey was very positive and painted a picture of general satisfaction with ECI. But there was a problem. About 1100 people submitted a survey. Of those, about 8% had kids currently in ECI programs (this is 88 surveys). This is a problem because 28,000 children receive ECI services each month (i.e. this represents 0.3% of the population). A response rate this low completely invalidates the results of the surveys, in other words the information is useless.

I asked about this and found out that the Feds did not want any ECI providers or DARS associated with distributing the survey (they might bias the results), so this means that it did not go out to very many parents.

APR:

I posted about ECI’s annual performance report earlier (see http://wp.me/pZf7K-65) as there are some challenges with it. I will have a lengthy phone conversation with DARS’ staff about the items relating to being a statistics geek (I did not want to drag out the meeting with things that only bother me), but the long and the short is that the DARS staff realize many of the shortcomings behind the indicators and measures being used in the report. The reality is that the federal Office of Special Education Programs is mandating many of these things even though they are flawed and don’t allow for meaningful conclusions to be drawn.

Some of these useless reports and surveys represent a great example of how we can save taxpayer dollars. People are paid to develop the reports and surveys, analyze them, write summaries, write follow ups, continually track the data, etc. Eliminating a lot of these would result in real savings to taxpayers and might alleviate the need to cut services to needy people.