arkansas health care reform task force – id/dd wait list
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Arkansas Health Care Reform Task Force – ID/DD Wait ListExploring Options for Addressing the Wait List for the DDS Alternative Community Services (ACS) Waiver Program for the Intellectually Disabled and Developmentally Delayed
March 2016
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Executive Summary• TSG reports what a new waiver benefit would look like for the
2,640 people on the ID/DD wait list• Top-5 benefits except Supportive Living
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Agenda• Review historical spending for Waiver program• Report results of a survey of households on the wait list• Model the effect of alternative capped a range of alternative
waiver programs• Recommend path forward
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Waiver Background• Improve the quality of services through Home and Community
Based Waiver Services provided under a 1915 waiver for a limited number of individuals as an alternative to ICF/ID placement
• Serving targeted populations: mental illness, and intellectual, developmental or physical disabilities with an age of onset before age 22
• Participation capped at 3,9881, with turnover, served 4,127 different individuals in SFY2015
• Wait list of 2,640
1 - http://humanservices.arkansas.gov/ddds/waiverDocs/ACSWaiverGuidebook.pdf
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Services• Supportive Living – enable beneficiaries to live in their own
homes, with their family, or in an alternative residence • Respite Services – short-term benefits for beneficiaries unable
to care for themselves due to absence of non-paid caregivers• Supportive Employment – enable beneficiaries who need
intensive ongoing support to perform in a competitive work setting
• Adaptive Equipment – equipment to increase, maintain or improve functional capabilities to perform daily life tasks
• Vehicle Modifications – adaptations to an automobile or van to accommodate the special needs of the beneficiary
• Environmental Modifications – modifications made to or at the beneficiary’s home
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Services (cont.)• Specialized Medical Supplies – items necessary for life support
not otherwise available under Medicaid• Supplemental Support Service – enable community living, in
response to crisis, emergency or life threatening situations• Case Management Services – assistance in gaining access to
needed services, in or out of the Waiver• Consultation Services – clinical and therapeutic services• Crisis Intervention Services – in the beneficiary’s home or
other local community site by a mobile intervention team• Community Transition Services – set-up expenses for
beneficiaries who are transitioning from an institution
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SFY2015 Services by Claim Amount
0
25,000,000
50,000,000
75,000,000
100,000,000
125,000,000
150,000,000
175,000,000
200,000,000
225,000,000
Supportive Living
Waiver Spending by Service
Transition Respite Care Consultative Specialized Medical Supplies Adaptive EquipmentSupported Employ-ment Case Management Supportive Living
Claims data from SFY2015 federal Expenditures Report
0 - 10,000
20,000 - 30,000
40,000 - 50,000
60,000 - 70,000
80,000 - 90,000
10,0000 - 110,000
120,000 - 130,000
140,000 - 150,000
160,000 - 170,000
180,000 - 190,000
>200,0000
100
200
300
400
500
600
700
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%81%
Cummulative
100%
Spending Levels by Beneficiary
Annual Claims Amount by Beneficiary
Num
ber o
f Ben
eficia
ries
96% of Waiver Spending is for Supportive Living20% of beneficiaries spend less than $20,000 – 80% less than $70,000
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Spending by Service Type
Service Type
Total Waiver Claims
Amount
Unique Beneficiary
Count
Average for Those Claiming Benefit Percent
Supportive Living 196,404,211 4,013 48,979 95.9%
Case Management Services 5,550,856 4,094 1,357 2.7%
Supportive Employment 668,300 103 6,617 0.3%
Specialized Medical Supplies 642,407 925 696 0.3%
Consultation Services 453,751 733 621 0.2%
Adaptive Equipment -ACS 392,835 155 2,568 0.2%
Respite Services 380,605 153 2,521 0.2%
Environmental Modifications 238,010 52 4,760 0.1%
Supplemental Support Service 16,462 17 1,097 0.0%
Adaptive Equipment - PERS Monthly Fee 13,733 31 474 0.0%
Adaptive Equipment - PERS Installation 479 6 120 0.0%
Total 204,761,648 4,124 49,675 100.0%
Claims data from SFY2015
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Supportive Living Averages $49,000
0 to 10,000
10,000 to 20,000
20,000 to 30,000
30,000 to 40,000
40,000 to 50,000
50,000 to 60,000
60,000 to 70,000
70,000 to 80,000
80,000 to 90,000
90,000 to 10,0000
10,0000 to 110,000
110,000 to 120,000
120,000 to 130,000
130,000 to 140,000
140,000 to 150,000
150,000+0
100
200
300
400
500
600
0%10%20%30%40%50%60%70%80%90%100%82%
99%
Supportive Living
Frequency Cummulative
Total Waiver Claim Amount per Person -- SFY 2015
Num
ber o
f Ben
efici
arie
s
Cum
ulati
ve P
erce
nt o
f Ben
efici
arie
s
Claims data from SFY2015
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Cost of Services Other Than Supportive Living
Case
Man
agem
ent S
ervi
ces
Supp
ortiv
e Em
ploy
men
t
Spec
ializ
ed M
edic
al S
uppl
ies
Cons
ulta
tion
Serv
ices
Adap
tive
Equi
pmen
t -AC
S
Resp
ite S
ervi
ces
Envi
ronm
enta
l Mod
ifica
tions
Supp
lem
enta
l Sup
port
Ser
vice
Adap
tive
Equi
pmen
t - P
ERS
Mon
thly
Fe
e
Adap
tive
Equi
pmen
t -PE
RS In
stal
latio
n0.01,000,000.02,000,000.03,000,000.04,000,000.05,000,000.06,000,000.0
0
2,000
4,000
6,000
1,357
6,617
696 621
2,568 2,521
4,760
1,097474 120
Historic Total and Average Costs of Services Other Than Living
Total Waiver Claims Amount Average for Those Claiming Benefit
Aver
age
Claims data from SFY2015
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Services other than Supportive Living Rarely Total More than $6,000
0 to 1,000
1,000 to 2,000
2,000 to 3,000
3,000 to 4,000
4,000 to 5,000
5,000 to 6,000
6,000 to 7,000
7,000 to 8,000
8,000 to 9,000
9,000 to 10,000
10,000 to 11,000
11,000 to 12,000
12,000 to 13,000
13,000 to 14,000
14,000 to 15,000
15,000 +0
500
1,000
1,500
2,000
2,500
3,000
3,500
0%10%20%30%40%50%60%70%80%90%100%
77%90%
96% 99%
All Claims other than Supportive Living
Total Waiver Claim Amount per Person -- SFY 2015
Num
ber o
f Ben
efici
arie
s
Cum
ulati
ve P
erce
nt o
f Ben
efici
arie
s
A program capped at $6,000 would meet 96% of needs other than Living Support
Claims data from SFY2015
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A Program Capped at as Little as $6,000 would Cover Most Historic Claims -- Except Supportive Living
02,0004,0006,0008,000
10,00012,00014,00016,00018,00020,00022,000
Spending by Current Waiver Beneficiary (Other than Supportive Living)
Individual Beneficiaries
Annu
al C
laim
s Am
ount
100%
Claims data from SFY2015
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Agenda• Review current spending for Waiver program• Report results of a survey of households on the wait list• Model the effect of alternative capped a range of alternative
waiver programs• Recommend path forward
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Survey Method• Survey invitation sent by US mail to 2,640 individuals on the
wait list• Asked to rank the top 5 most important benefits from the list• Respondents responded by using a web survey• Asked for comments at the end of the survey• Offered the opportunity to respond anonymously or provide
detailed contact information• Respondents spent an average of 8 minutes responding (long
for a web-based survey). This suggests they took it seriously
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Responses Covered the State
Note: 81% of responses provided name and address, only these are graphed
• 440 responses in 10 days—17% response rate
• 81% provided addresses
• All but one provided a comment
• Responses represented the entire state
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How the Services were Ranked
Supporti
ve Li
ving
Respite Se
rvice
s
Case Management S
ervice
s
Supporti
ve Employm
ent
Environmental M
odifications
Consultation Se
rvice
s
Adaptive Equipment
Supplemental S
upport Se
rvice
Community Transiti
on Servi
ces
Specia
lized M
edical S
upplies
Vehicle M
odifications
Crisis I
ntervention Se
rvice
s0
50
100
150
200
250
300
350
400
450Services Ranking in the Survey
n=440
Rank 5
Rank 4
Rank 3
Rank 2
Rank 1
Num
ber o
f Res
pons
es
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Services by Rank
Rank 1 Rank 2 Rank 3 Rank 4 Rank 50
50
100
150
200
250
300
350
400
450Services Ranking in the Survey
n=440
Crisis Intervention ServicesVehicle ModificationsSpecialized Medical SuppliesCommunity Transition ServicesSupplemental Support ServiceAdaptive EquipmentConsultation ServicesEnvironmental ModificationsSupportive EmploymentCase Management ServicesRespite ServicesSupportive Living
Num
ber o
f Res
pons
es
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Summary Findings from Survey• Supportive Living is #1, but not as strongly favored as the 97%
of current Waiver participants that claim for Supportive Living • Respite and Case Management are clear #2&3 for those on
the wait list• Responses are widely dispersed—strongly supporting the
notion of self-determination of services• Response rate, and number, size and tone of comments all
suggest that the wait list is a very unhappy group, looking to the legislature for quick relief
• Respondents would rather have some benefits even if it is less that the whole Waiver program
• Respondents seek more self-direction• The selection process should be faster, clearer and more
transparent
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Agenda• Review current spending for Waiver program• Report results of a survey of households on the wait list• Model the effect of alternative capped a range of alternative
waiver programs• Recommend path forward
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What if…• TSG has modeled a waiver like those in Indiana, Tennessee and
Kentucky. It would…• Provide a benefit capped at an amount much smaller that the
average of claims for those already on the Waiver• Allow recipients substantial latitude to spend up to the cap on
any of the services. Both models assume that for most beneficiaries, the capped amount would not be sufficient to fun a meaningful part of Supportive Living
• This model considered simply for the purpose of understanding what might result from such a capped benefit
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TSG Developed the Model Based On• Assumptions:• Services usage based on survey responses• Services cost based on historic Waiver claims• Assuming the program would allow beneficiaries to claim services
up to the cap• Excluding Supportive Housing from the value assessment, as we
know it averages $50,000, beyond other state caps• Seeking to find out:
1.What services would beneficiaries likely spend the capped amount on?
2.How far would the capped benefit go towards “buying” all of their 5 highest ranked services?
3.How much would the two scenarios cost in total, assuming 2,640 people came off the wait list into the new waiver program
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03,0006,0009,000
12,00015,00018,00021,00024,00027,00030,000
Simulated Beneficiary Claims
Rank 1 Rank 2 Rank 3 Rank 4 Rank 5
Annu
al E
stim
ated
Cla
ims
Self-Directed Benefit Simulation
72% of top-5 needs (other than Supportive Living) met by a cap of $12,00086% by a benefit capped at $15,000
The #4 & #5-ranked services are often the more expensive ones
72%
86%
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Agenda• Review current spending for Waiver program• Report results of a survey of households on the wait list• Model the effect of alternative capped a range of alternative
waiver programs: Next Task Force Update• Recommend path forward
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Full Cost of Capped Waiver for 2,640 on the ID/DD Wait List
Capped at $12,000
Capped at $15,000
Beneficiaries capped benefit: all services $31,680 MM $39,600 MMArkansas State Match Cost $9,504 MM $11,880 MM