full cost analysis of hhr-dbhds budget final
TRANSCRIPT
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PreliminaryAnalysis
oftheHealthandHumanResourcesBudget
fortheSettlementAgreement
RobertW.Anthony,Ph.D.*
MemberoftheBoardParents&AssociatesoftheNorthernVirginiaTrainingCenter
December4,2012
*Dr.AnthonysqualificationsarefoundinAttachmentI.
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ExecutiveSummary
OnJanuary31,2012,HealthandHumanResourcesbriefedtheSenateFinanceCommitteeontheirbudget,estimatedtorequire$340.6millioninnewGeneralFund[s],tocoverthecostsofthenowfinalSettlementAgreementwiththeU.S.DepartmentofJusticeandtheexecutivebranchsdecisiontotransitioncurrent
residentsofVirginiasTrainingCentersintocommunityplacements.SinceHHRdidnotpubliclydocumenttheirsourcesandmethods,thisanalysisreconstructstheHHRBudgetfrompostingsonthewebbyHHRandtheDepartmentofBehavioralHealthandDevelopmentalServices.ThisanalysisclarifiestheinterpretationoftheHHRBudgetandprovidesabasisforexaminingitsassumptionsandcoverage.
LeavingallfiveofVirginiasTrainingCentersopenwouldlikelyhaveaneutraleffectorsaveVirginiasGeneralFundmoremoneythanwouldclosingfourofthem,asplanned.TheHHRBudgetassumesIDwaiverratesthatwererecognizedbyallpartiesnottobeadequatetosupportmostcurrentTrainingCenterresidents,manyofwhomcamethereafterfailingtofindadequateplacementsinthe
community.Providersandpeer-reviewedscientificresearchbothestimatethatadequatecommunityplacementsforthisveryvulnerableandchallengingpopulationwillcostasmuchasTrainingCenterplacements.
TransitioningresidentsofTrainingCenterstothecommunityincreasesmortalityrisks.Reducingthelevelofsupportaftertransitionorhurryingthetransitionprocessexacerbatestheserisks.Mostcommunityplacementsaretoosmalltojustifythecostoftwostaffontheovernightshiftthatprovidesemergencybackupandinhibitsabuseandneglect.Accesstonursingandprofessionalservicesiseitherdelayedorveryexpensiveifonsite.Characteristicssuchasthesecauseanestimated72percenthighermortalityforthosetransitionedtothecommunity.
SmallregionalTrainingCenterswouldappeareconomicallyviableandpreservetheconnectionsbetweenresidentsandtheirlocalcommunity.Over97percentofAuthorizedRepresentativespolledwantthosetheyrepresenttoremainintheirlocalTrainingCenter.MoveswouldsevertieswiththefourvolunteersforeachresidentatNVTC.BycitinglowerperpersonratesatcommunityIntermediateCareFacilities,theHHRBudgetbriefopensupforconsiderationtheoptionofsmallerregionalTrainingCenters.
Thisanalysisshowsthehugeleveragethatwaiverratesandcontinuedunmetneedsinthecommunityhaveoverthetotalbudgetforwaiverplacements.TrainingCentersmightprovidesomerelief.TheHHRBudgetdoesnotshowthe
underlyingbaselinebudgetofapproximately$4.5billionforthosealreadyreceivingsupportsforID/DDin2012,abudget13timeslargerthanthenewGeneralFundrequestof$340.6million.Overall,communitysupportsconstitute80percentoftotalfundingforID/DD.Ifthe8.1percentgrowthrateofIDwaivercostsduringthelastdecadecontinuesthroughtheSettlementAgreementperiod,itwouldadd$1.9billionor48percentmoretothe10-yearbudget.OrganizationalintegrationandeconomiesofscaleatTrainingCentersofferoptionstocontaincostsforthosefewwiththemostintenseprofessionalservicesandbehavioralmanagementneeds.
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SummaryofFindings
Thisanalysisisofferedinacooperativespirit.AlthoughitfocusesonapparentproblemswiththeHealthandHumanResourcesBudgettocoverthecostsofthe
nowfinalizedcourtSettlementAgreementandoftheexecutivebranchsdecisiontoclosefourofitsfiveTrainingCenters,thepurposeistoalertpolicymakerstotheseproblemssothattheycanputVirginiaonthebestpathtoabetter,moreintegratedsystemofsupportsforthosewithIntellectualDisabilitiesandDevelopmentalDisabilities.
OnJanuary31,2012,theSenateFinanceCommitteewasbriefedontheHHRBudgettocoverthecostsofthenowfinalizedSettlementAgreement.TheHHRBudgetalsoassumedthatallcurrentresidentsofVirginiasfiveTrainingCenterswouldtransitionintocommunityplacements.Sincetherearenopublicdocumentsgivingtheanalyticalsupportforthosefinalamounts,itisverydifficultforinterested
partiestoidentifytheplanningassumptions,uncovertheunstatedcostbaselineuponwhichtheHHRBudgetbuilds,orassesstheappropriatenessofindividualperpersonrates.AnyoneoftheseaspectscouldsignificantlyimpactfutureGeneralFundobligations.
ThisanalysisreverseengineerstheprincipalcostitemsintheHHRBudget,basedonannualperpersonratespostedonthewebbyHHRandtheDepartmentofBehavioralHealthandDevelopmentalServices.AftervalidatinganapproximateunderstandingoftheHHRBudgetconstruction,theanalysisexaminestheunderlyingassumptions,thediscrepanciesbetweendifferentsourcesofinformation,majorcostdrivers,andalternativesthatmightimprovethesystemofsupports.
TheImpactofKeepingTrainingCentersOpen
LeavingallfiveofVirginiasTrainingCentersopenwouldlikelyhaveaneutraleffectorsaveVirginiasGeneralFundmoremoneythanwouldclosingfourofthem,asplanned.
ThereasonwhyleavingthecentersopenwouldcostthesameorlessthanclosingthemliesininaccuraciesintheHHRBudget.ItoverestimatesthecostofTrainingCenterplacementswhileunderestimatingthecostofcommunitysupportsforthoseleavingacenter.Onbalance,TransitionWaiverSlotsarelikelytocostasmuchasTrainingCenterplacements.
CommunitycostswillbemuchhigherthanestimatedbyHHR.ASeptember18,2012HHRbriefingestimatedtheTransitionWaiverswouldcost,onaverage,$104,000perpersonannually.ModelinganalysisoftheHHRBudgetagreeswiththisrateassumption.SincethosewhohavebeenabletosuccessfullyleaveTrainingCentersforcommunityplacementsatthislowratehavebeenthoserequiringtheleastchallengingsupports,onewouldexpectpeopleremaininginCenterstoneedmuchmorecostlysupport.Moreover,theDBHDShasrecognizedthatthewaiverfundingisinadequatetoservethispopulation.A2010DBHDSreportstated,The
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disparity[infunding]makesitdifficultforthosewithcomplexmedicalorbehavioralconditionstoreceivesufficientcareandservicesundertheIDwaiverprogram.1So,whentheHHRBudgetintheJanuary31,2012,briefingdocumentassumedthatMedicaidwaiverstructureandproviderratesdonotchange,itwasassuminglowercostsforwaiversthanwillbeneededtocareforpeople
transitioningfromTrainingCenters.
AdditionalevidencecastsseriousdoubtontheHHRBudgetbriefingassumptionthatthemaximumcostfortransferstothecommunitywouldcost$138,000peryear.ThisrateappliedtocommunityIntermediateCareFacilitiesforthosewithMentalRetardationin2011,butunlikeTrainingCenters,theseICFsoftenwillnotacceptapplicantswhoarenotmobileorhaveotherchallengingconditions.Foradifferentyear,a2009analysisbyBraddockandothersshowcommunityICFratesforVirginiathatareapproximatelythesameasthoseforTrainingCenters.2TheiranalysiscitesperpersonratesincommunityICFsas$251,000forthosewith15orfewerbeds,withanaverageoverallsizesof$217,000.
TrainingCentercostsarelowerthantheHHRBudgetestimate.InJanuary2011,DBHDSciteda$216,000perpersonrateforNorthernVirginiaTrainingCenterbutonlya$181,000rateasthestatewideaverage.3TheHHRBudgetusedthehigherratefortheirestimationofFacilitySavingsratherthantheloweraveragenumberconsistentwiththewaivercostsinthatearlierperiod.ThisapparentinconsistencyinchoosingtheNVTCrateartificiallyincreasedtheFacilitySavingsby$163.1million,whichis55percentofthe$295.5millionnetsavingsHHRestimatesforclosingTrainingCenters.
Overall,communityproviderestimatesandpeer-reviewedacademicresearchindicatethatTransitionWaiversplusotherlocalgovernmentcostswillroughly
equalthecurrentcostofsupportingresidentsinTrainingCenters.AssumingnodifferenceincostbetweenTrainingCenterandwaivercostswouldeliminatethe$295.4milliondollarnetsavingsfromclosingTrainingCentersestimatedintheHHRBudget
MakingbetteruseofthepropertiescouldreduceTrainingCentercostsfurther.Forexample,theDBHDScouldhave,butdidnot,considerthecostsavingproposalsputforwardintheNorthernVirginiaRegionalPlandevelopedbystakeholdersfromacrossthespectrumofTrainingCenterandcommunityorganizations.4
1NorthernVirginiaTrainingCenterDiversionPilot,DBHDSReport,Item314E.,November1,2010.2Braddock,Hemp,Rizzolo,Haffer,Tanis,andWu,StateoftheStatesinDevelopmentalDisabilities2011,DepartmentofPsychiatry,UniversityofColorado,2011.3JamesStewart,III,MajorIssuesFacingtheCommonwealthsBehavioralHealthandDevelopmentalServicesSystem,abriefingpresentationtoajointmeetingofSenateEducation&HealthandtheHouseHealth,Welfare&InstitutionsCommittee,January13,2011.4RecommendationsforservicedeliverywithinHPRRegionIItoenhanceservicesforindividualswithintellectualdisabilitiesthroughcollaboration,NVTC,CSBs,andothers,November19,2010.
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ThesimplestestimateofcostsavingsfromnotclosingTrainingCentersis$89millionoverthe10yearsoftheSettlementAgreement.ThisisprimarilythemoneybudgetedtotransitioncurrentTrainingCenterstaffintootheremployment,andconstitutes26percentoftheHHRnewGeneralFunds.
NeedlessRisksandFalseSavingsfromHurriedClosingsTransitioningresidentsofTrainingCenterstothecommunityincreasesmortalityrisks.Reducingthelevelofsupportaftertransitionorhurryingthetransitionprocesspossiblywithneedlessmovesexacerbatestheserisks.
TheHHRBudgetplannersassumedthat213TrainingCenterresidentswouldeitherdieorotherwiseleaveTrainingCenterssothattheinitialstatewidecensusof1018couldbeaccommodatedoverthe10yearsoftheSettlementAgreementbyonly805waivers.ForthisHHRplantoworkasdesigned,thosevacatingTransitionWaiverslotsinthecommunitywouldhavetobereplacedbyotherTrainingCenterdischargestofillthosewaivers.Subsequently,modificationstotheSettlementAgreementshouldreducethisconstraintbyexplicitlystatingtherighttopermanentresidencybythosewhochosetoremaininaTrainingCenter.
TheonlywaytoachievesignificantcostsavingsbydischargetothecommunitywouldbebyareductioninthelevelofsupportthatcurrentTrainingCenterresidentsenjoy,butthiswouldalmostcertainlyelevatethemortalityrateofthosedischargedtothecommunity.About84percentofTrainingCentercostsareforprofessional,directcarestaff,andotheressentialsupports;thus,cuttingcosts,cutssupports.Professionalsvisitingcommunityresidentsspendapproximately25percentoftheirtimeintravel.Traveltime,therefore,rendersimpracticalthefrequentshortpreventativecarevisitsnowenjoyedbyTrainingCenterresidents.Acultureofcaringwithever-presentsocialpressureistheprincipalimpedimenttoabuse,neglect,orerror.Butsmallfourbedhomescouldnotaffordtohaveone,letalonetwo,peopleondutyatnight.Suchareductioninsupportswould,baseduponthefindingsofpeer-reviewedstudies,exacerbateanobserved72percenthighermortalityrateincommunityplacements.Thistranslatesintoanestimated74excessfatalitiesoverthedurationoftheSettlementAgreement,a35increaseoverthatexpectedwithoutdischargesfromTrainingCenters.
TherearemanygoodreasonstodelaythescheduleforclosingSVTCandNVTC.Theadministrationhasset2014and2015asthedatesforSVTCandNVTCtocloseinordertomaximizetheiranticipatedcostsavingsneededtoimplementtheSettlementAgreement.AnyresidentswhoremaininaTrainingCenteratthe
scheduledtimeofclosurewouldbemovedtoCVTC,whethertheyremainbecausetheychooseaTrainingCenterplacementorsimplycannotfindadequatecommunityplacementunderthecurrentwaiver.SuchanapproachvaluesanadministrativegoalmorethanthepreferencesoftheauthorizedrepresentativesfortheresidentstoremaininSVTCandNVTC.RemovaltoCVTCwouldalsodenyfamilyandfriendsreadyaccesstoseeingtheirlovedones.ItwouldalsodenytheresidentscontactwiththefourvolunteersforeachresidentatNVTC,andthemorethanthe20yearsofexperiencemanydirectcareworkershavewithNVTCresidents.
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If,asexplainedabove,adequatecommunitysupportscostasmuchasTrainingCenterplacements,thenthereisnocostadvantagetoadheringtoanartificialscheduleforclosures.Instead,anyclosuresshouldbebasedonatimetablethatassuresthebestoutcomefortheresidents.OneobviousbenefitofaslowerclosurescheduleforSVTCandNVTCwouldbetotakeadvantageoftherestructuredwaiver
tobeputinplacein2014or2015.Inaddition,aslowerschedulefordischargewouldprovidetimetotesttheeffectivenessofthenewcrisismanagementandqualitymanagementsystemsandtoanalyzetheoutcomesofcommunityplacementsforTrainingCenterresidentswhoelectthatoption.
ReasonstoPreserveSmallerRegionalTrainingCenters
SmallregionalTrainingCenterswouldappeareconomicallyviable,andtheypreservetheconnectionsbetweenresidentsandtheirlocalcommunity.
NearlyallAuthorizedRepresentativeswanttheirlovedonestoremainintheircurrentregionalTrainingCenter.AtSVTC,AuthorizedRepresentativescontinuallyadvocateforretainingTrainingCenterplacements.AtCVTC,informalpollsofAuthorizedRepresentativesrevealednearunanimousdesiretoremainatCVTC.AtNVTC,97percentofthosepolledwouldchoosetoremain.SubsequenttotheearlierHHRBudgetbriefing,thefinalSettlementAgreementreaffirmedtherightofAuthorizedRepresentativestochoseaTrainingCenteroption.GiventhelargenumberofpeoplewhowishtoremaininTrainingCentersandthecomparabilityofcoststocommunitycosts,wouldntitmakemoresensetodevelopalternativeplansforasignificantnumberofresidentstoremainintheirexistingTrainingCenters?
SmallerregionalTrainingCentersappeartobecostcompetitive.AccordingtotheHHRBudgetbriefing,smallcommunityICFsweregivenasanexampleofcostefficiencyforthecommunity.PerhapsDBHDScouldalsooperatesmallerstateICFs,thatisTrainingCenters,economically.
AUnderlyingBaselineBudgetandCostDrivers
Thisanalysisshowsthehugeleveragethatwaiverratesandcontinuedunmetneedsinthecommunityhaveoverthetotalbudgetforwaiverplacements.TrainingCentersmightprovidesomerelief.
RestructuringthewaiveranditsrateswouldbethedominantfactordrivinguptheneedfornewGeneralFunds.WhiletheHHRBudgetbriefingshows$340.6millioninnewGeneralFundmoneyisneeded,HHRsBudgetdoesnotshowtheunderlyingbaselinebudgetofapproximately$4.5billionthatisbeingexpanded,13
timeslargerthanthenewGeneralFundsof$340.6million.LookingattheentirebudgetforID/DDrevealsthat80percentofthecostsforsupportsdependdirectlyonwaiverrates.Giventhatthewaiverneedstoberestructuredanditsratesincreased,especiallyifthosewithinvolvedconditionsaretoleaveTrainingCenters,thiswillputgreatpressureonthetotalbudgetforID/DD.
Methodologicalaside:Uptothispoint,theanalysisadoptedannualratesforwaiversandTrainingCentercostsgivenintheHHRBriefingorDBHDSreports,andthese
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reproducetheHHRBudgetratherclosely.ButbroadeningtheanalysisrequiresmoreconsistencyinthetimeframeoftheratesHHRchoseandwhatsupportswereincludedinthoserates.Withconsistentrates,analysiscouldreconstructtheunderlyingbaseline,examinetheimpactofrateinflationover10years,assesstheconsistencyofthetimeframeamongtheratesHHRadopted,andestimatethe
impactofrestoringthenumberofnewwaiversperyeartothe360enjoyedbetween2003and2010.
Thevarioussourcesonratesappeartohavebeentakenfromdifferentyearsand,withoutbetterdocumentation,thisanalysisreconcilestheseasfollows:Thisanalysischosethe2012waivercostof$75,465fromtheHHRUpdatebriefingtomatchthe$224,245rateforTrainingCenterplacementsalsofromtheHHRUpdatebriefing.ButthisanalysiscouldnotdeterminefromthesepublicDBHDSsourceswhethertheratesincludechildren,DaySupports,AcuteCarecosts,orotherpossiblecontributions.Nonetheless,themajorconclusionsshouldhold,althoughactualdollarvaluesmightshiftwithmoreconsistentsourcesforrates.Assumingthatthe
TrainingCentersremainopenshouldbebudgetneutral,hencetheartificialrateof$104,000forTransitionWaiversdoesnotapplytothisanalysis.
ContinuedIDwaiverinflationof8.1percentwouldincreasetotalIDwaivercostsby$1.9billionor48percentovertheir$3.9billion10-yearbaselinewithoutinflation.TrainingCentercostsincreasedfrom$181,000to$224,245over33months,alsoan8.1percentannualincrease,yetonly33monthscannotestablishapreciseestimateofaveragerate.
TrainingCenters,evenatsomewhatsmallersize,offervaluableeconomiesofscalethataremoreinsulatedfromnursingshortagesandwaiverrateuncertainties.Asanexampleofaneconomyofscale,TrainingCentersefficiently
usenursingsupport.Inthecommunity,nursesupportwouldonlyavailablebyphone,withaboutanhourstraveldelay,ataTraining-Center-likecrisisstabilizationcenter,orathighcostforworkinginsmallresidences.
ShouldtheGeneralAssemblychoosetofundonlytherequiredaverageof291waiversperyear,attheendoftheAgreement,theurgentwaiverlistwouldbelongerthanitisnowsinceitgrowsatroughly350peryear.TheSettlementAgreementcallsforanaverageof291newwaiversannually,mostforpeopleontheurgentwaitinglist.AstheGeneralAssemblyprovided360suchwaivers,onaverage,between2003and2010,oneshouldexpectthatcommunityadvocateswouldrequestacomparablenumberofnewwaiverseachyear.Possiblyadvocateswould
evenasktheGeneralAssemblytohonortheir2009legislationpromising400newIDwaiversannually.Providing360Waiversinsteadof291wouldadd$145.2million,or43percentmoretotheHHRnewGeneralFunds.Providing400additionalWaiverswouldadd$208.9million,or61percentmoretothenewGeneralFunds.
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AnalyticalSupportandDiscussion
Tobeastransparentaspossible,thisanalysispresentsitssources,methods,andresultsinamannerthatinterestedreaderscouldtracefromassumptionstoconclusion.Italsopresentsusefulcollateralinformation,discussestheimplications
oftheresults,andofferssomesuggestions.Hopefully,thiseffortwillimprovetheclarityandfocusofsubsequentdeliberationsandoffersomeinsightandoptionsforcontrollingcostswhileresponsiblysupportingthosewithsignificantIDorDD.
1.SourcesandMethods
ThisanalysistestsitsdatasourcesandmethodsbyreproducingtheHHRBudgetandthenappliesthatunderstandinginacritiqueofHHRsunderlyingplanningassumptions.ThelargestcostitemsintheHHRBudgetrepresenttheaggregatecostofsupportingmanyindividualswithIDorDD.ButsinceDBHDSdidnotpublishtheirsourcesusedtoderivetheHHRBudget,thisanalysisobtainstheindividualperpersoncostsmostlyfromwebpostingsofHHR,DBHDS,andotherreputable
organizations.Toreproducetheanalysisbeginswiththeannualratesperperson,accumulatesthenumberofperson-yearsfromthescheduleintheSettlementAgreement,andmultipliesthosenumbersbytheirrespectiverates.CloseagreementbetweentheseestimateditemcostsandtheitemcostsgivenbyHHRBudgetshowsthatthemajorcontributionstothebudgethavebeenidentified.
WithanunderstandingoftheannualratesusedbyHHR,thisanalysisoffersseveralreasonsandsupportingevidenceshowingthattheindividualizedannualratesforcommunityplacementsofthosetransitioningfromTrainingCentersareinadequateformostresidents.Measuredagainstthismoreappropriatesetofratesforthecommunity,leavingallTrainingCentersopenwouldlikelysavemoney.The
onlyalternativewaytosavemoneyistoseverelyreducesupportsofferedinthecommunity,therebygreatlyincreasingthemortalityrateforthosedischargedfromTrainingCenters,anunethicalalternative.
Otherfindingsofthisworkemploysourcesandmethodsthatareexplainedincontextalongwiththeirresults.Forsimplicity,MicrosoftExcelwasemployedforallcalculations,andotheranalystscouldeasilyreproducethecalculationsfromthisdescription.Asameansoflatercrosscheckingthecalculations,numbersarereportedastheycameouttoseveraldigits.Theseextradigitsarenotaclaimofhighprecisionasthesecalculationsareonlyapproximatevaluesgoodtothefirstfewdigits.
EveryonereviewingtheHHRBudgetmustrealizethatitrepresentsamarginalcostcomparedwithaverylargeunstated,orunderlyingbaseline.Thisbaselineconsistsofthe10yearsofaccumulatedcostsofsupportingthosealreadyonwaiverinthecommunity,thenumberofwaiverslotsrequiredbytheSettlementAgreement,andthecostsoftheresidentscurrentlyinTrainingCenters,assumingtherewerenodischarges.Overthe10yearsoftheSettlementAgreement,aroughestimateofthisunderlyingbudgetbaselineisapproximately$4.5billion,whichis13
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timeslargerthanthenewGeneralFundsintheHHRbudget,thatis,$340.6million.
2.PerPersonAnnualRates
ToestimatethelargerHHRBudgetitemcosts,thisanalysisneedstheratesfor
individualsupports,whicharetheaverageannualcostsperpersonreceivingthesupport.Table1liststhenecessaryratesforID,DD,andTransitionWaivers,FamilySupports,andTrainingCenterplacements.Notethatmostsourcesareeitherfrom2010or2012,whichleadstosomeconfusion.
TheItemandSourcecolumngivesthedocumentsourceand,insomecases,explainshowtherateswerederivedfromthesourceinformation.Boxesframethesourcenumber,andheavyboxesdesignatethosesourcesusedtoreconstructtheHHRBudget.IfthesourcedocumentdoesnotgivetheGeneralFundfraction,theTotalRatewassplitinproportiontotheGFandNon-GFamountsgivenintheHHRBudget.
ThereweretwosourcesforthecostofIDwaivers,onethatwouldapplytoplanninggoinginto2010andtheotherfor2012.ButmodelingwillshowthattheHHRBudgetemployedthe2010numbers.Thelarger2012numberforIDwaiversmighthaveincludedotherelementssuchasacutehealthcareorDaySupports,butthiswasnotmadeclear.Bycontrast,theHHRBudgetaveragerateforTrainingCenterswasfortheplanningyear2012.ASeptemberupdatebriefingfromHHRgaveanevenhigherrate.Futurebudgetestimatesshouldexplainwhatiscoveredincommunitysupportsandemploythesamebaselineyearfortheirplanningrates.
AlthoughmostoftheserateswerepubliclypublishedbyDBHDSorothergovernmentagencies,theywerenotprovidedbyHHRinresponsetoaFreedomof
InformationActrequest.5Intheinterestoftransparencyofgovernment,thesesourcesshouldbeprovidedforfuturebudgetbriefingsandreports.
A.UnderstandingtheHHRBudget
MortalityplaysalargeroleinreducingtheTrainingCentercensusover10years,andtheanalysisexaminesthemortalityassumptionsandthenmodelstheimplicationsoftheseassumptionsonboththenumberofTransitionWaiversandtheFacilitySavingsbudgetitem.SincethemethodsforanalyzingTrainingCentercostsapplyequallywelltotheCommunityWaiversandSupports,thefinalsection
completesthecomparisontotheHHRBudgetbaseline.
AllbudgetmodelingisovertheSettlementAgreementperiod.JustasfortheHHRBudget,thisanalysisassumesconstantdollarsanddoesnotadjustfortheexpectedannualincreasesinwaiverratesorTrainingCenterrates.
5LetterfromMatthewCobb,DeputySecretaryofHHR,toRobertAnthony,Ph.D.,datedMarch19,2012.
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Item%and%SourcePlanning%%%%%%
Date
General%%%%%
FundNGF
Total%%%%%%%%%%
Rate
Individual)ID)Waiver)from)Plan)to)Eliminate)Waiting)List*
2010 $31,855 $30,195 $62,050
Individual)ID)per)Capita)Cost)Including)
Acute)Care)from)VBPD)Assessment,)2011**2010 $31,893 $42,834 $74,727
Individual)ID)Waiver)Cost)from)HHR)
Update,)September)2012*2012 $38,742 $36,723 $75,465
Individual)DD)Waiver)from)Plan)to)
Eliminate)Waiting*2010 $13,353 $12,657 $26,010
Individual)DD)per)Capita)Costs)from)VBPD)
Assessment,)2010**2010 $16,080 $18,379 $37,768
Private)communication*** $3,000 OO OO
DBHDS)Briefing,)Jan)2011)and)University)of)
Minnesota)Report,)2010*2010 $92,922 $88,078 $181,000
ICF/MR)Expenditures)per)Person)for)
January)2011,)VBPD)2011)Assessment*2011 $100,404 $95,170 $195,574
Annual)cost)of)a)TC)placement)from)HHR)
Budget)Brief)and)DBHDS)Brief,)Jan)
2011****
2012 $110,899 $105,408 $216,000
Annual)cost)of)a)TC)placement)from)HHR)
Update,)September)2012*2012 $115,124 $109,121 $224,245
DBHDS)Briefing,)Sept)2012* )2012***** $52,000 $52,000 $104,000
Note)that)boldOline)boxes)designate)rates)used)in)reconstructing)the)HHR)Budget,)while)the)paleOline)
boxes)designate)values)from)other)regerences.
*)General)Fund)portion)was)calculated)in)proportion)to)HHR)Budget)item)split)between)GF)and)total)of)
GF)and)NonOGF.
**)General)Fund)portion)was)calculated)by)dividing)total)GF)expenditures)by)census.
***)Another)source)places)a)tight)limit)on)$3,000:)"DJ)Implementation)Update")DBHDS,)page)16,)July,)
2012,)gives)the)total)cost)for)1,000)Family)Supports)in)2014)as)$3.2)million,)or)$3,200)per)person.
****)The)2011)DBHDS)Briefing)gave)$216,000)as)the)rate)for)NVTC)alone)but)the)statewide)average)as)$181,000.))Nonetheless,)the)HHR)Budget)calculation)from)this)time)period)employed)the)$216,000)rate)
instead.))The)General)Fund)portion)was)calculated)in)proportion)to)the)split)between)GF)and)NonOGF)in)
the)HHR)Budget.
*****)HHR)Budget)was)assembled)from)numbers)as)recent)as)late)2011;)however,)the)origin)of)the)
$104,000)rate)cited)in)the)HHR)Update)Briefing)remains)unclear.
Table%1.%Rates%(Annual%Cost%per%Person)%and%Their%Sources%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
for%the%HHR%Budget%Items%Estimated%by%Modeling
ID%Waiver%Rates
DD%Waiver%Rates%
Family%Supports
Training%Center%Rates
Transition%Waiver%Rates%for%Discharges%from%Training%Centers
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1.MortalityandWaiverSlotsforDischargesfromTrainingCenters
Losstomortalityoverthe10yearsoftheSettlementAgreementaccountsformostofthe213otherwiseunaccountedforpeoplegiventhattheoriginalplanningbaselinecensuswas1018TrainingCenterresidentsbutonly805TransitionWaiverslotswereoffered.
a.AssumptionsaboutMortality
ReproducingtheeffectofmortalityonTrainingCentercensusrevealsHHRplannersmortalityrateassumptionsandillustratesthemethodsusedthroughoutthisanalysis.
Table2showstwomethodsforcalculatingthedecliningcensusfrom1018to805over10years.Thefirstcalculatesthenumberoffatalitiesfromthemortalityrateassumingeveryonealiveatthebeginningoftheyearremainssothroughouttheyearandthensubtractsthosefatalitiesattheendofeachyeartoyieldthecensusforthesubsequentyear.Sincetherearesomefatalitiesduringtheyear,thesecondmethodestimatesfatalitiesbasedonthemid-yearcensus.Toreducethecensusfrom1018to805bytheJanuary2022,themid-yearmethodmustassumeaslightlyhighermortalityrateof23.5per1,000peryearratherthan23.2fortheend-of-the-yearmethod.Notshowninthetableisacontinuousmodelofmortalityforwhichamortalityof23.6per1,000wouldbenecessarytodropthecensusto805in10years.
Year Census Fatalities Census Fatalities
2012 1018 23.6 1018 23.6
2013 994 23.1 994 23.12014 971 22.5 971 22.5
2015 949 22.0 949 22.0
2016 927 21.5 927 21.5
2017 905 21.0 905 21.0
2018 884 20.5 884 20.5
2019 864 20.0 864 20.0
2020 844 19.6 844 19.6
2021 824 19.1 824 19.1
2022 805 213 805 213
Fatalitiesper1000 23.2 23.5AverageAnnualFatalities 21.3 21.3
Table&2.&Discrete&Models&of&Training&Center&Mortality&over&10&Years
Mid?YearDecrementEndofYearDecrement
Althoughthismortalityrateisnearlythreetimesasgreatasthe8.6per1000forthenormalpopulation,itisstillasmallpercentage,about2.3percentperyear.Therefore,thediscretemethodsareaquitesatisfactorysubstituteforthemoreexactcontinuousmethod.
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Nonetheless,HHRhasassumedaratethatishigherthanthetypicalrateforVirginia.ThefollowingtableshowsthatVirginiasTrainingCentershaveanexcellentrecordofpreservingthelivesoftheirresidentscomparedtothenationalaverage.
Table&3.&Baseline&Mortality&Rates&per&1000&for&State&ICF/MRs
2009 2010 2009 2010
1,259 1,197 33,682 30,602
28 24 870 820
22 20 26 27
Sources:Larkin,Larson,etal.,ResidentialServicesforPersonswithDD,
Univ.ofMinnesota,2010and2012.
Virginia USAItem
Averagedailypopulation
Numberofdeaths
Mortalityper1000population
Since213fatalitiesamongtheTrainingCenterpopulationoverthenext10yearsisastatisticalexpectation,within95percentconfidencetherecouldbeasmanyas21fewerdeathsandmoredemandforTransitionalWaivers.Subsequently,the
SettlementAgreementwasrevisedsothatsomeresidentscouldremainiftheirAuthorizedRepresentativeschoseforthemtostay.ThisprovisionoftheAgreementwillprobablyreducethedemandforTransitionWaivers.
b.UsingTransitionWaiverSlotsOpenedbyMortality
FortheHHRplantoworkasdesigned,somewhatmorethan23residentsper1000wouldhavetodischargewithoutusingaTransitionWaiver,andthosevacatingTransitionWaiverslotsinthecommunitywouldhavetobereplacedbyotherTrainingCenterdischargestofillthosewaivers.Table4parallelsTable3whileshowingtheTransitionWaiverplacementsasagrowingcensusinthecommunity.Notethatfatalitiesinthecommunitymakeroomformoredischarges
toOldWaivers.Overall,thetotaloftheEmptyingTrainingCentercensusplustheWaiverPlacementcensusequalstheoriginalcensuswithoutdischarges.Similarly,thefatalitiesintheTrainingCentersplusthoseinthecommunityalsosumtotheoriginalnumberoffatalities.
2.HHRFacilitySavingsandTransitionWaiverSlots
FacilitySavingsshownintheHHRBudgetaretheaccumulatedcoststhatwouldhavebeenincurredifresidentshadremainedintheTrainingCenters.Therefore,asimplewaytoestimateFacilitySavingsistomultiplytheperson-yearsinwaiverplacementsbytheportionoftheTrainingCenterratethatcomesfromGeneralFunds.Similarly,TransitionWaivercostsarethesamenumberofperson-yearsmultipliedbythewaiverrateforthoseleavingTrainingCenters.
Table5showsbothoftheseaccumulations,mid-yearcorrections,andcomparisonswiththeHHRBudgetbaseline.FacilitySavingsestimatesagreewiththeHHRBudgettowithin3percent,andTransitionWaiverestimatestowithin6percent.BothoftheseestimatescanbebroughtintoexactagreementwiththeHHRBudgetbyshiftingthemid-yearpointtoMarchandFebruaryrespectively.
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Year Census FatalitiesNew/
WaiversCensus Fatalities
Old/
WaiversCensus Fatalities
2012 1018 23.6 60 1018 23.6 0 0 0.0
2013 994.4 23.1 160 934.4 21.7 1.4 60 1.4
2014 971.3 22.5 160 751.3 17.4 5.1 220 5.1
2015 948.8 22.0 90 568.8 13.2 8.8 380 8.8
2016 926.8 21.5 85 456.8 10.6 10.9 470 10.9
2017 905.3 21.0 90 350.3 8.1 12.9 555 12.9
2018 884.3 20.5 90 239.3 5.6 15.0 645 15.0
2019 863.7 20.0 35 128.7 3.0 17.1 735 17.1
2020 843.7 19.6 35 73.7 1.7 17.9 770 17.9
2021 824.1 19.1 0 19.1 0.4 18.7 805 18.7
2022 805.0 213 805 0.0 105.3 107.6 805 107.6
Fatalities/per/1000 23.2 Training/Centers 23.2 Community 23.2
No/Discharge/ Emptying/Training/Centers Waiver/Placements
Table&4.&Baseline&with&Discharges&to&Transition&Waivers&in&the&Community
Facility(((((((((
Savings*
Tranistion(
Waivers**
GF#Portion#of#Rate#= $110,899 $52,000
Year TC#Waivers All#Waivers Costs Costs
2012 60 0 $0 $0
2013 160 60 $6,653,944 $3,120,000
2014 160 220 $24,397,795 $11,440,000
2015 90 380 $42,141,646 $19,760,000
2016 85 470 $52,122,563 $24,440,000
2017 90 555 $61,548,984 $28,860,0002018 90 645 $71,529,900 $33,540,000
2019 35 735 $81,510,816 $38,220,000
2020 35 770 $85,392,283 $40,040,000
2021 0 805 $89,273,751 $41,860,000
Total 805 4640 $514,571,682 $241,280,000
MidEYear#Correction 403 $44,636,875 $20,930,000
Corrected#Total 5043 $559,208,558 $262,210,000
HHR#Budget#Item $573,800,000 $278,400,000
Difference#to#HHR#Budget ($14,591,442) ($16,190,000)
Percent#Difference#= E3% E6%
*#GF#cost#is#a#0.5134#fraction#of#$216,000#Training#Center#rate#given#in#
####HHR#Senate#Finance#briefing#on#January#31,#2012.
**DBHDS#adopted#current#total#cost#of#waivers#for#those#leaving#
#####Training#Centers#of#$104,000#per#year#as#their#planning#baseline.##
####General#Funds#pay#half#of#each#Waiver.
HHR(Budget(Item
Table(5.(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
HHR(Budget(General(Fund(Items:(Facility(Savings(and(Transition(Waivers((((((
and(HHR(Budget(Anticipated(Net(Savings(from(Training(Center(Closures
$295,400,000
HHR#Budget#Net#savings#=#[Facility#Savings]#E#[Trainsition#Waivers]
Fromthisanalysisitisobviousthatthenet$295.4millionthatHHRanticipatestogainbyclosingTrainingCenterresultsfromthedifferenceintheTrainingCenter
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rateperpersonandtheTransitionWaiverrate.SectionBbelowwillanalyzethisanticipateddifferencefromseveralperspectives.
3.BaselineCostsforCommunityWaiversandFamilySupports
TherearethreeseparatecomponentstoHHRBudgetitemCommunityWaiversand
Supports:IDwaivers,DDwaivers,andFamilySupports.Eachhasadifferentperpersonrate(GFPortionofRate)andscheduleofnewslots(New)intheSettlementAgreement.
GF#Portion#of#Rate#= $31,855 GF#Portion#of#Rate#= $13,353 GF#Portion#of#Rate#= $3,000
NewPerson######
YearsCosts New
Person######
YearsCosts New
Person######
YearsCosts
2012 275 275 $8,760,244 150 150 $2,002,965 0 0 $0
2013 225 500 $15,927,717 25 175 $2,336,792 700 700 $2,100,000
2014 225 725 $23,095,189 25 200 $2,670,620 1000 1700 $5,100,000
2015 250 975 $31,059,048 25 225 $3,004,447 1000 2700 $8,100,000
2016 275 1250 $39,819,292 25 250 $3,338,275 1000 3700 $11,100,0002017 300 1550 $49,375,922 25 275 $3,672,102 1000 4700 $14,100,000
2018 325 1875 $59,728,938 25 300 $4,005,930 1000 5700 $17,100,000
2019 325 2200 $70,081,954 25 325 $4,339,757 1000 6700 $20,100,000
2020 355 2555 $81,390,633 50 375 $5,007,412 1000 7700 $23,100,000
2021 360 2915 $92,858,589 75 450 $6,008,895 1000 8700 $26,100,000
Total 2915 14820 $472,097,526 450 2725 $36,387,196 8700 42300 $126,900,000
MidDYear#Correction 1458 $46,429,294 225 $3,004,447 4350 $26,100,000
Corrected#GF#Total 13363 $425,668,232 2500 $33,382,749 37950 $113,850,000
I/#Waivers#Family#Supports $572,900,981
HHR#Budget#Item $575,400,000
ifference#= ($2,499,019) Percent#= D0.4%
ID#Waivers# DD#Waivers Family#supports
Table#6.#General#Fund#Costs#of#Providing#Community#Waivers#and#Family#Supports#on#Settlement#Agreement#Schedule:###################################
Estimation#and#Comparison#with#the#HHR#Budget
Year
EstimatesforthesethreecommunitybenefitscombinedpredicttheHHRBudget
within0.4percent.ThiscompletesthecomparisonwiththeHHRBudgetshowingthatHHRandDBHDSsourcesprovidesufficientinformationtoreconstructthelargestcontributions.
B.NoFacilitySavingsfromTransitionCosts
IftheTransitionWaiverratesandotherassociatedgovernmentcostsequalorexceedtheTrainingCenterrates,thendischargingaresidentfromaTrainingCentertothecommunitywouldhavenoeconomicbenefit.ThereisampleevidencethattransitioncostswouldinfactequalorexceedTrainingCenterplacementcostsifthe
qualityofcommunitysupportswerecomparable.Butthereisahighriskofsavingcostsbyofferingmuchinferiorsupportsincommunityplacements.Thisriskmightexplainthegreatermortalityratesobservedinthecommunityforthosewithcomparablelevelsofdisability.
1.NoSavingsforTransitionwithComparableSupports
Asbestthisanalysiscoulddiscern,theHHR/DBHDSemploysthemostoptimisticannualwaiverratesfortheirestimateofcommunitycostsandpessimisticratestoestimateTrainingCentercosts.MorerealisticexpectationswouldbethatTransition
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WaiverswouldcostasmuchasTrainingCenterplacements,onneteliminatinganysavingsfromtransitioningresidents.
a.CommunityCostsWillBeHigherthantheHHRBudgetAssumed
AhostofreasonsindicatethatTransitionWaiversarelikelytocostasmuchas
TrainingCenterplacements. TheHHRplannersmistakenlyusedcurrentwaivercostof$104,000for
dischargingaresidentfromaTrainingCenterasrepresentativeofthewaivercostforallfuturedischarges.6Todate,thoseabletofindcommunityplacementswithinthecurrentwaiverlimitationssystematicallyrepresentapopulationwithlessinvolvedconditions.Forexample,manyresidentsofTrainingCentersaretherebecausetheyfoundrefugeafterfailingtobesuccessfullysupportedinthecommunityasaresultofhealthorbehavioralissues.
ThecurrentwaiverisinadequateforthoseinTrainingCenterswiththemoreinvolvedconditions.AsearlyasOctober17,2007,DBHDSsubmittedareporttotheGovernorlistingthedeficienciesofthecurrentWaiver.7ThesummaryhasalreadyquotedDBHDSfromtheItem314E.report,NorthernVirginiaTrainingCenterDiversionPilot,dated2010expressingtheinadequacyofcurrentwaivers.Morerecently,SecretaryHazelsApril17,2012,lettertoMr.MartinNohe,ChairmanoftheNorthernVirginiaRegionalCommission,stated,IwanttoassureyouthattheGovernorandIarecommittedtorestructuringtheMedicaidwaiverprogramsthatcurrentlyserveindividualswithintellectualanddevelopmentaldisabilities.TwoofthesesourcespredatedtheHHRBudgetBriefingtoSenateFinanceonJanuary31,2012,thatmadethegeneralassumption,Medicaidwaiverstructureandproviderratesdonotchange.
TheHHSBudgetbriefingalsoassumedacaponcommunityservicecostsof$138,000perpersonperyear.InclusionofthisfigureimplicitlyrecognizesthatsomepeoplemovingfromtheTrainingCenterswillrequireanICFlevelofcare,whichispermissibleundertheSettlementAgreement.Later,aDBHDSbriefingandanotherreportverifiedthatthiscostrepresentsa2010averageforexistingcommunityICFs.8SincemanyofcommunityICFswillnotacceptTCresidentswithcomplexconditions,forexample,thosewhoarenotmobile,thiscostcapisunreasonablylow.
Recentacademicanalysiscitesperpersoncostsas$251,000forcommunityICFswith15orfewerpersonsinVirginia,andanaverageof$217,000forcommunityICFsofallsizes.9
6Slide4ofSecretaryHazelsbriefing,UpdateonVirginiasSettlementAgreementwiththeU.S.DepartmentofJustice,totheJointCommissiononHealthCare,September18,2012.7PlanforEliminationofWaitingListunderMedicaid:ID&IndividualFamilyDDSupportsWaivers,OfficeoftheGovernor,October1,2009.8Alsoonslide4ofSecretaryHazelsSeptember2012briefingandVirginiaBoardforPeoplewithDisabilities,AssessmentoftheDisabilityServicesSysteminVirginia,June2011.9Braddock,Hemp,RizzoloHaffer,Tanis,andWu.TheStateoftheStatesinDevelopmentalDisabilities2011,Dept.ofPsychiatryandColemanInstituteforCognitiveDisabilities,UniversityofColorado,2011.
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Peer-reviewedacademicresearchshowsthereisnodiscernablesavingsfromtransferringTrainingCenterresidentstocommunityplacements.10Walshetal.pointoutthatmanycostsareshiftedtootherGeneralFundorlocalbudgetsandthereforehiddenfromthesimplecomparisonofwaivertoTrainingCenterplacement.
PrivatevendorssuchasResourcesforIndependenceofVirginia(RIVA)estimateitwouldrequire$600to$650perday($219,000to$237,250peryear)tosupportmanythatliveinNorthernVirginiaTrainingCenteriftheymovedtothecommunity.
b.TrainingCentersCostsWillBeLowerthantheHHRBudgetAssumed
TworeasonssuggesttheHHRBudgetbaselinecostsforTrainingCenterplacementsareinflated.
WhiletheHHRBudgetbriefingtoldSenateFinancetheaveragecostofaTrainingCenterplacementwas$216,000perpersonperyear,aDBHDSbriefing
toSenateEducationandHealthCommittee1yearearliergavetheaveragecostas$181,000,whilethe$216,000figurewasjustforNVTC.11TheDepartmentofJusticeusedothersourcestociteastateaverageof$195,000thatcorrespondsintimewiththe$138,000figurequotedbyHHRBudgetbriefingforacaponcommunitycosts.12Adoptingthe2010annualTrainingCenterrateof$181,000peryear,tobeconsistentwiththeotherratesintheHHRBudget,wouldreducetheFacilitySavingsby$161.0million,henceincreasingtheHHRestimateofnewgeneralfundingby47percent.
DBHDShasnotconsideredorimplementedoptionsforreducingthecostsofoperatingTrainingCenters.Forexample,DBHDSdidnotevencommentontheNorthernVirginiaRegionalPlanworkedoutbyabroadcoalitionofcommunity
andTrainingCenterstaffandparentstosavemoneywhilepreservingthequalityofsupports.13 TheratesatNVTCareartificiallyhighbecausetheyinclude11newdischarge
officerpositionstobepaidbytaking$700,000fromtheNVTCbudget,non-essentialpositionsthatprovidenocaretoresidents.Similarpositionsatsomeothertrainingcentersalsoartificiallyincreasecentercosts.
10KevinK.Walsh,TheodoreA.Kastner,andReginaGentleskGreen,MentalRetardation ,Vol.41,No.2:103-122(April2003).11James,W.Stewart,MajorIssuesFacingtheCommonwealthsBehavioralHealthandDevelopmentalServicesSystem,apresentationtotheJointMeetingoftheSenateEducation&HealthCommitteeandtheHouseHealth,Welfare&InstitutionsCommitteeVirginiaGeneralAssembly,January2011.12AssessmentofDisabilityServicesinVirginia,VirginiaBoardforPeoplewithDisabilities,June2011.13RecommendationsforservicedeliverywithinHPRRegionIItoenhanceservicesforindividualswithintellectualdisabilitiesthroughcollaboration,NVTC,CSBs,andothers,November19,2010.
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2.SavingsfromReducedSupports
Unfortunately,thecostsoftransitioningpeoplefromTrainingCenterstocommunityWaiverscouldalsobesavedbyrestrictingorlimitingaccesstoessentialservices.Thesesavingsalmostcertainlywouldleadtothehighermortalityrates.
a.ReductioninServicesThereislittlelatitudeforreducingNVTCcostswithoutreducingprofessionalanddirectstaffsupports.Forexample,personnelcostsaccountfor83.8percentoftheNVTCbudget,andanother8.9percentgoestowardvocationalplacements,food,medical,andothersupplies;seeTable7below.Atleast90percentofstaffcostgoestowardsupportstoresidentssinceprofessionalstaffwagesaremuchgreaterthansupportstaff;seeTable8below.Togetherabout84percentofallNVTCcostsareessentialtosupportingresidentservices.Theremainingoverheadforasinglefacilitycannotbeexcessiverelativetothemanagementofmanysmall,dispersedcommunityresidentialandsupportsites.TheprofileofcostsattheotherTrainingCentersislikelysimilar.
Transportation costs associated with community supports should more thanoffsettheunavoidableoverheadcostsofrunningaTrainingCentercampus.InNorth Carolina, their START crisis management program similar to the oneVirginiaisimplementingfindsstatewidethat24percentofcoordinatorstimeisspentintravel.14Time isspent coveringthe longdistances inruralareasandfightingtrafficcongestioninurbanareas.Forprofessionalssuchasnurses,whowouldneed to travel to clients, community placementsmust also absorb thisoverhead cost. Generalizing this specific finding to all other professionalservicesquantifies theobvious factthataccess to services involvessignificanttraveltime,eitherbytheprofessionaloradriverandattendantwiththeclient.
b.ReasonstoExpectHigherMortalityintheCommunity
ExperiencesacrossthecountryandinVirginiaunderscorethehigherrisksofmortalityinthecommunityandprovidesomeinsightintothereasonswhy.CommonsenseandfindingsfromthestudyofhumanbehaviorrevealthechallengesthatasystemofcommunitysupportsfaceincomparisontothenaturalprotectionsofferedbyTrainingCenterenvironments.
NationalNewsReports:InvestigativenewspaperarticlesinWashington,D.C.byKatherineBoo,1999,andinNewYorkbyHakimandBuettner,2011,whofound,morethan1,200(deathsingrouphomes)inthepastdecadehavebeenattributedtoeitherunnaturalorunknowncauses,aswellasmassiveabuse,
neglect,anddeathsofpeoplewithIDlivingingrouphomesinthoseareas.InNewYork,itrequiredagut-wrenchingnewsarticletobringthesetravestiestothepublicsattention.Thisillustratesthepoliticaldilemmafacedbyagencieschargedwithprotectingthemostvulnerableamongus:theymustaggressively
14NorthCarolinaSystematic,Therapeutic,Assessment,RespiteandTreatmentprogram(NCSTART)AnnualReport,January2010June2011,publishedbytheNCSTARTCentral,EastandWestTeams,October2011.
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investigatethemselvestomaintainreasonablelevelsofprotectionfromabuseandneglect.
Item Percent
Personnel 83.8%
Contracting*and*Information*Technology 3.8%
Off*Campus*Vocational*Placements 4.2%
Food,*Medical*and*Other*Supplies 4.7%
Insurance 1.0%
Utilities*and*Equipment*Rentals 1.8%
Life*and*Safety*Code*Costs 0.4%
Equipment*Purchases 0.4%
Total 100.1%
Total*NVTC*buget*is*$36.4*million.
Table7.NVTCBudgetfor2011
Personnel(Category Number Percent
Degreed(/(Licensed(Professionals 76 16%
Direct(Support(Professionals 266 55%
Administration/Management(Personnel 63 13%
Support(Personnel(housekeeping,(maintenance,(dining,(security) 82 17%
Total 487 100%
Table&8.&Staffing&at&Northern&Virginia&Training&Center&as&of&December&2011
VirginiaOversight:In2011,Mr.TugglewasscaldedbyaccidentandlaterdiedasaresultofhisburnsbecausethegrouphomemanagerwasnotwillingtosendMr.Tuggletothehospital,presumablytocoveruptheaccidentalharm.Thisexampleillustrateswhyself-reportisuntrustworthyasaprimarybasisforoversightandunderscoreswhatcommonsensewouldsuggest.15
TransitionRisks:Acourt-orderedclosureoftheBeatriceStateDevelopmentalCenterinNebraskaledto12deathsin25monthsamongthe47infragilehealthwhoweredischarged.Thismortalityrateis20timesthatinthepreviousyearatBeatriceand10timesthatinVirginiasTrainingCenters.16
Thedispersionandsmallsizeofcommunityresidentialunitscreatesstructuralbarrierstoprovidinganintensive,responsive,andsafesystemofsupports.
Dispersionofthosereceivingservicesprecludestheeasymonitoringfromfrequentshortvisitsbyprofessionalstaff,andthetimedelaysoftravelby
15PressreleasefromAttorneyGeneralCuccinelli,II,filedMay25,2012,Cuccinelliannouncesguiltyverdictofgrouphomeownerresponsibleforabuse,neglect,anddeathofintellectuallydisabledvictim.16Dr.TedKastner,privatecommunication.
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professionalsleavedirectcarestaffontheirowntosolveproblemsorhavingtorelyontelecommunicationlinks,bothofwhichposeabarriertoaccessingrealhelp.
Traveldelaysandoverwhelmedon-sitestaffwithoutbackupexacerbaterisksinlifethreateningsituationsifmultipleemergenciesoccuratonce.
Implementingeffectiveoversightinthecommunityisvirtuallyimpossiblesincemonitoringreliesprimarilyonself-reportbyproviders.Ofcourse,someproviderswoulddiligentlyreportproblemsandofferexceptionalservices,buttheprovidersorstaffposingthegreatestriskstoresidentscanalsobeexpectedtoavoidcandidreporting.TheaccidentaldeathofMr.Tuggleillustratesthisobviousdilemmaforthoseinoversight.Morefrequentunannouncedinspectionswouldhelp,buttheseareunlikelytodeterabuse,neglect,oraccidentsashoped.17Thebestprotectionfromabuse,neglect,oraccidentishavingmorethanonestaffpersononsiteatalltimestoobserveaninfractionorprovidebackupifoneresidenthasanemergency.TrainingCentersandsomelargercommunityfacilitiesmeetthiscondition,but
smallercommunityplacementsdonot.
c.HigherMortalityintheCommunity
Experiencewithcommunityservicesandpeer-reviewedscientificresearchshowthattherearehighermortalityratesinthecommunityforthosewiththelevelsofdisabilitytypicalofmostoftodaysresidentsofTrainingCenters.ModelingprovidesameansofquantifyingthisfortheHHRplan.Themostsignificantimpactofhighermortalityinthecommunityisanexpectednet74morefatalitiesthanifcurrentresidentswerepermittedtoremaininTrainingCenters,fully35percentmore.
Strauss,Kastner,andShavelleconductedthelargestacademicstudycomparingmortalityinstateoperatedICFswiththefullspectrumofcommunityplacements.18Theyemployedappropriatestatisticalmethodsandanalyzed131,152person-yearsofdata.Theystratifiedtheircomparisonaccordingtocomparabledegreesofdisabilityalongtwoscales:mobilityandself-careskills.Only10percentofthoseinthecommunityhadsignificantdisabilitiesweremorethanhalfwayuponafour-categoryscaleoneitherofthetwodisabilityscales.Fully51percentofstateICFresidentsweremorethanhalfwayupononeortheotherdisabilityscale.Straussetal.concludedthatifthestateICFresidentshadbeenlivinginthecommunitytheywouldhavea72percenthighermortalityratethanintheirpresentinstitutionalplacement.
17Deterrencedoesnottakeeffectuntilthelikelihoodofbeingcaughtrisesaboveadeterrencethresholdthatdependsupontheseverityofthepenalty.Conductingtheresearchtofindthethresholdisdifficult,butfromfisheriesviolationsbyscofflaws,monitoringwouldhavetoapproachafewpercentofallon-the-jobtimehardlypracticalwithperiodicvisits.RefertoAnthony,ACalibratedModelofthePsychologyofDeterrence,UnitedNations,BulletinonNarcotics,vol.LVI,Nos.1and2,2004.18Strauss,Kastner,andShavelle.MortalityofAdultswithDDinCaliforniaInstitutionsand
CommunityCare19851994,MentalRetardation,October1998.
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AlthoughthestudywasconductedinCaliforniaover17yearsago,subsequentstudiesofmoremodestscalealsoachievingalevelofstatisticalsignificancehaveconsistentlyfoundanelevatedrateofmortalityinthecommunity.19Supportpracticeshaveprobablyimprovedsincethis1998study,butthelevelofdisabilityofthoseinTrainingCentershasalsoincreasedasthosewhowerebettersuitedfor
communityplacementshaveleft.Risksofmortalitywentfrom16.1per1000forthestate-runICFsinCaliforniaduringtheperiod1985to1994to30per1000in2010.InVirginia,mortalityinTrainingCentersarehighbutsignificantlylowerthaninCalifornia,22to20per1000forin2009and2010respectively.SinceintheCaliforniastudyfoundthatthosewiththenoself-careskillormobilityhad2.5timeshighermortalityinthecommunity,itisreasonabletoadoptthe72percenthighermortalityrateforcommunityplacementsinVirginia.ThisratedifferentialfacilitatesmodelingthemortalityimplicationsofclosingTrainingCentersinVirginiaoverthe10yearsoftheSettlementAgreement.
Table9showstheimpactofa72percenthighermortalityrateinthecommunityon
theexpectednumberofdeathsofformerTrainingCenterresidentsafterdischarge.PalepurplebackgroundcoloremphasizestheearlyemptyingoftheTrainingCentersby2021leavingtheremaining35TransitionWaiverslotstobefilledbypeoplefromthewaitinglist.PaleredhighlightsthetotalnumberoffatalitieswithoutdischargesfromTrainingCenters(213)andwithdischargesaccordingtotheSettlementAgreementschedule(287).Thedifferenceof74excessdeathsis35percentmorethanifTrainingCenterresidentshadremainedinplace.
Fromthisanalysis,manyparents,guardians,andAuthorizedRepresentativesrealisticallyunderstandthatamovefromaTrainingCenterplacementtothecommunityislife-threateningdecision.TheDBHDShasnotconductedandpublishedscientificallysoundanalysistoassessthemortalityimpactsoftheirplansnorhavetheymadepublicanyplanstodosoduringtheimplementationoftheSettlementAgreement.WithoutscientificallyvalidresearchmethodsappliedtothemortalityexperiencedamongthisvulnerablepopulationofpeoplewithID/DD,smallnumbersofneedlessdeathsgounnoticed,andtherearenosubstantivestandardsformaintainingqualitysupports.TheDBHDScoulddothefollowingtomaintainstandardsandvisibilityoftheneedsofthisvulnerablepopulation:
19Subsequentresearchhasfoundhighermortalityinthecommunityaccordingtoprivatecommunicationwithoneoftheauthors,Dr.Kastner.
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Year Census FatalitiesNew/
WaiversCensus Fatalities
Old/
WaiversCensus Fatalities Census Fatalities
2012 1018 23.6 60 1018 23.6 0 0 0.0 1018 23.6
2013 994.4 23.1 160 934.4 21.7 2.4 60 2.4 994.4 24.1
2014 971.3 22.5 160 750.3 17.4 8.8 220 8.8 970.3 26.2
2015 948.8 22.0 90 564.1 13.1 15.2 380 15.2 944.1 28.3
2016 926.8 21.5 85 445.9 10.3 18.8 470 18.8 915.9 29.1
2017 905.3 21.0 90 331.8 7.7 22.1 555 22.1 886.8 29.8
2018 884.3 20.5 90 211.9 4.9 25.7 645 25.7 856.9 30.7
2019 863.7 20.0 35 91.3 2.1 29.3 735 29.3 826.3 31.4
2020 843.7 19.6 35 24.8 0.6 30.7 770 30.7 794.8 31.3
2021 824.1 19.1 0 0.0 0.0 32.1 805 32.1 805.0 32.1
2022 805.0 213 805 0.0 101.4 185.2 805 185.2 805.0 287
Fatalities1000 23.2 Fatalit ies1000 23.2 Fatalities1000 39.9
Ratio/of/mortality/(Waiver/slots//Training/Centers)/= 1.72
Excess/mortality/=/(287/M/213)/=/ 74
Color/Codes:
Table&9.&Impact&of&the&Scheduled&Transition&from&Training&Centers&to&Waiver&Placements&on&Expected&Mortality
Training/Centers Waiver/Placements Grand/Total/CheckNo/Discharge
Impact/on/schedule:/Early/emptying Impact/on/mortality:/Excess/Fatalities
Implementscientificallyvalidatedreviewsofmortality:Analyzemortalityaccordingtorecognizedriskfactorsandsearchforotherriskfactors.Publishthesefindingsinpeer-reviewedjournalstoestablishtheindependenceofthereviewsfrompoliticaloradministrativepressures.
Providetimetorecognizeexcessfatalitiesduringthetransition:UsingFishersexactmethodtocomputethechanceoftheexcessnumberoffatalitieshappeningbychance,thisanalysisfoundthatitwouldtake2yearsbeforethatchancewouldexceedthescientificallyacceptedstandardof1:20odds.ThisslowingdowntherateofdischargesfromTrainingCenterswouldprovidetimetoanalyzecommunityperformance.
Providepublicaccountabilitytoassureparents,guardians,andAuthorizedRepresentatives:PubliclyreleasetheresultsoftheseanalysesandstatisticalfindingsandothermeasuresoftheeffectivenessofthesupportsforthosewithID/DD.MostpeoplewithID/DDwilloutlivetheirparents,andasystemofpublicaccountabilityispartialassurancethattheneedsofthesemostvulnerablecitizens,whocannotadvocateforthemselves,willbemet.
3.TabularSummaryofRealBudgetSavings
Table10consolidatestheHHRBudgetitemsscatteredthroughouttheHHRBudgetbriefingintoasinglelist,giveninthefirstcolumn.TheRealisticBaselinecolumneliminatesthegapbetweenTrainingCenterandcommunitywaiverrates,hence
eliminatingtheartificial$295.4millionthatDBHDSanticipates.TheTrainingCentersRemainOpencolumnshowsthesimplifiedcaseofleavingall2012residentsinplace,whichyieldsareal$89.2millionsavingsrelativetotherealisticbaseline.IfasmallpercentageofcurrentTrainingCenterresidentschoosecommunityplacementsandafewstaffhaverelocated,itshouldnotsubstantiallyaffectthisrealsavings.
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Transition)Waiver)Slots!for!TC $278.4 $573.8 $0.0
WTA/Other!TC!employee!transition $89.2 $89.2 $0.0
Facility)Savings ($573.8) ($573.8) $0.0
Community)Waivers)and)Supports $575.4 $575.4 $575.4
Crisis)Programs* $120.0 $120.0 $120.0
Waiver)Administration* $26.1 $26.1 $26.1
Quality)Management* $25.1 $25.1 $25.1
FY)2012)Trust)Fund)Deposit** ($30.0) ($30.0) ($30.0)
FY)2012)Items)in)Base** ($169.8) ($169.8) ($169.8)
$340.6 $636.0 $546.8
Difference!to!HHR!Briefing!baseline $0.0 $295.4 $206.2
Percentage!excess!over!HHR!Baseline 87% 61%
Difference!to!realistic!baseline $0.0 ($89.2)
Percentage!excess!over!HHR!Baseline J26%
Color!Key:
!Trace!Requires!Modeling !Changed!from!Baseline
!Baseline!Reference !More!Realistic!Baseline !Savings!with!Training!Centers
*!!Required!by!the!Settlement!Agreement!and!not!analyzed!further!here.
**!Already!committed!General!Funds!and!not!analyzed!further!here
The!net!total!for!all!items!designated!by!(*)!and!(**)!is!$28.6!million!of!credit!toward!other!costs.
Table)10.)Cost)Savings)by)Leaving)Training)Centers)Open))))))))))))))))))))))))))))))))))))))))))))
When)Compared)with)Realistic)Baseline)Costs
Total)New)General)Funds
HHR)Budget)ItemsHHR)Briefing)
Baseline
Realistic)
Baseline
Training)Centers)
Remain)Open
C.TrainingCenterSizeandLocation
Parents,siblings,family,guardians,andotherAuthorizedRepresentativesgenerallywishtohavetheirlovedonesnearby.Furthermore,partiesconcernedwiththewelfareofTrainingCenterresidentshavenotbeenprovidedanyeconomicorsubstantivereasonswithsupportingevidencefortheurgentscheduleofTrainingCenterclosingsorclosingsratherthandownsizing.
1.ReasonstoDelayClosures
Countertotheirplannersassumptions,DBHDSnowknowsthatthecommunitywillnotbereadytoacceptthosewiththemostchallengingconditionsbeforethe
scheduledclosuresofSVTCin2014andNVTCin2015.Nonetheless,DBHDSclaimsitmustshowprogressbyadheringtothescheduledclosuredates.Ifso,thiswouldforceparentsandAuthorizedRepresentativestochoosebetweenacceptinginadequatecommunityplacementsnearbyorwatchingtheirlovedonesbeingrelocatedtoaremoteTrainingCenterselsewhereinthestate.20TheDBHDS
20ThesepointscameoutduringameetingbetweenNVTCParentsandAssociatesmeetingwithSecretaryHazelonNovember16,2012.
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shouldeitherpresentcompellingsubstantivereasonsforclosingSVTCandNVTCbeforethecommunityisreadyordelaytheclosingsuntilthecommunityhasdemonstrateditisadequatelypreparedtoacceptthosetobedischarged.
2.ReasonstoMaintainaSmallerTrainingCenterinEachRegion
SurveysatCVTCandNVTCrevealthatover95percentofAuthorizedRepresentativesofcurrentTrainingCenterresidentswanttheirlovedonestoremainwheretheyare.DuringtherestructuringofSEVTC,asubstantialmajorityoftheAuthorizedRepresentativeselectedfortheirresidentstoremaininthenewrainingCenterplacements.TheprospectofalargefractionofcurrentTrainingCenterresidentsnotchoosingtotransitionisalsocountertotheassumptionsoftheDBHDSplanners.
IfalargefractionofcurrentTrainingCenterresidentsweretoremaininTrainingCenters,thisanalysiscannotidentifyanysubstantiveadvantagestoconsolidatingofthoseresidentsintofewercentersratherthansustainingsmallercentersineachregionofthestate.
HealthandHumanResourceshasalreadyarguedthatquitesmallICF/MRsarepracticaltoconsider.Bythislogic,itshouldsupportthepreservationofsomewhatdownsizedTrainingCentersineachRegionofVirginia.Slide3oftheHHRBudgetbriefingstatesthat,Theannualstatewideaveragecommunitycostis$138,000perpersonforthosewithcomparablecareneedsasTrainingCenterresidents,andslide4ofHHRsrecentupdatebriefingacknowledgesthattheyarereferringtocommunityIntermediateCareFacilities.21AlthoughthisanalysispointedoutreasonsthatcommunityICFratesareunlikelytocoverTrainingCenterresidentneeds,DBHDSnonethelessmadetheargumentthatsmallerICF/MRsarepractical.InVirginia,thecommunityICF/MRsisgenerallysmall,averaging10.7bedseach.22
ThebestinterestsofTrainingCenterresidentsandtheirfamilyandfriendsarguesthattheresidentsshouldbesupportedinnearbylocations,irrespectiveoflocallaborratesandlandvalues.Iftransitionedtothecommunity,thoseplacementswouldcostmoresimplybecauselandvaluesandwagesarehigherinmoreprosperousregions.ResidentsofmoreexpensiveregionscontributetheirfairsharetothewealthoftheCommonwealthandshouldbeabletoenjoytheirfairshareofstateservices.
21SecretaryWilliamHazel,HealthandHumanServicesPresentationtoSenateFinance,January31,2012,andUpdateonVirginiasSettlementAgreementwiththeU.S.DepartmentofJustice,briefingtotheJointCommissiononHealthCare,September18,201222VirginiaBoardforPeoplewithDisabilities,AssessmentoftheDisabilityServicesSysteminVirginia,page262,June2011.
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D.RestoringtheRateofNewWaiverCreation
AdvocatesofexpandingcommunitysupportsarelikelytopressuretheGeneralAssemblytorestoretheincreaseinnewWaiversthattheyreceivedinrecentyears.
1.PressuresforMoreNewWaiversThenumberofnewcommunityIDWaiversrequiredbytheSettlementAgreementaverages291peryear,manyfewerthanthe360peryearaveragethatadvocateshavebeenabletoobtainfrom2003thru2010;seeTable11.23Furthermore,AnActrelatingtoeliminationofwaitinglistsfortheMentalRetardationMedicaidWaiverandIndividualandFamilyDevelopmentalDisabilitiesandSupportMedicaidWaiverwithin10years,approvedinMarch,2009,specifiesfundingatleast400newwaiverseachyear.24TheGovernorsreportcitedaboveshowsthatitwouldrequireasmanyas1,100newwaiversperyeartoeliminatethewaitinglistin10years.Approximatelyhalfthat,550peryear,wouldberequiredtoeliminatejusttheurgentwaitinglist.With5,932peopleonthewaitinglist,itsannualgrowthrate
is699/5,932=12percentperyear.
Year ID'slots DD'slots
2003 150 0
2004 175 0
2005 860 105
2006 0 0
2007 303 65
2008 468 100
2009 710 15
2010 210 15
Average 360 38
Table&11.&Established&Rate&for&New&&&&&&&&&&&&&&&&&&&&&&&&&&&
ID&and&DD&Waivers&in&Virginia
2.CumulativeCostsofIDWaivers
Usingthesamemethodsasbefore,Table12showsthecumulativecostsofproviding360newIDwaiverseachyearor400newwaiversyearly.Table12showstheGeneralFundcostsforthesmaller2010baselineIDwaiverrates.Thefollowingpointsputthisresultinperspective:
360newIDwaiversperyearwouldincreasetheCommunityWaiversandSupportsitemoftheHHRBudgetby$145.2million,or25percent.
400newIDwaiversperyearwouldincreasetheHHRBudgetitemby$208.9million,or36percent.
23PlanfortheEliminationofWaitingListsunderMedicaid:IntellectualDisabilities&IndividualandFamilyDevelopmentalDisabilitiesSupportsWaivers,OfficeoftheGovernor,October1,2009.242009ActsofAssemblyChapter228/Chapter303.
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360newwaiversperyearwouldincreasetheHHRBudgetnewGeneralFundsby43percent,and400newwaiversperyearwouldincreaseitby61percent.
IfalloftheTransitionWaiversbecamenewIDwaiversforthecommunity,over10yearsthiswouldbe2,915+805=3,720,whichisonlyslightlylargerthan360x1,000=3,600restoringthehistoricalpaceofnewIDwaivercreation.
GF#Portion#of#Rate#= $31,855 GF#Portion#of#Rate#= $31,855
Year NewPerson######
YearsCosts New
Person######
YearsCosts
2012 360 360 $11,467,956 400 400 $12,742,173
2013 360 720 $22,935,912 400 800 $25,484,347
2014 360 1080 $34,403,868 400 1200 $38,226,520
2015 360 1440 $45,871,824 400 1600 $50,968,6942016 360 1800 $57,339,781 400 2000 $63,710,867
2017 360 2160 $68,807,737 400 2400 $76,453,041
2018 360 2520 $80,275,693 400 2800 $89,195,214
2019 360 2880 $91,743,649 400 3200 $101,937,388
2020 360 3240 $103,211,605 400 3600 $114,679,561
2021 360 3600 $114,679,561 400 4000 $127,421,734
Total 3600 19800 $630,737,586 4000 22000 $700,819,540
MidDYear#Correction 1800 $57,339,781 2000 $63,710,867
Corrected#GF#Total 18000 $573,397,805 20000 $637,108,672
I/#Waivers#Family#Supports $720,630,554 $784,341,421ifference#= $145,230,554 ifference#= $208,941,421
Percent#ifference#= 25% Percent#ifference#= 36%
Typical(Number(2003((2010 Legislated(Promise
Table(12.(General(Fund(Costs(of(Increasing(the(Number(of(New(ID(Waivers(per(Year
E.UnderlyingBaselineforHHRBudget
TheHHRBudgetrepresentsthemarginalchangefromabaselineofmaintainingindividualsnowonwaiversandnowinTrainingCenters,plusthecostofnewwaiverslotsincludedintheSettlementAgreementovertheperiodfromJanuary1,2012throughtheendofDecember2021.Thisunderlyingbaselineisverylargeand
managingitsaggregatecostshasimplicationsforkeepingTrainingCentersopenornot.Specifically,thebaselinedominatestherenegotiationofthewaivertocovercurrentTrainingCenterresidentneeds,anditrevealsthepossiblevalueofTrainingCentersincostcontainment.
1.SizeoftheUnderlyingBaseline
Table13showsthehiddenbaselineofGeneralFundsaswellasthenewmoneyforsupportingtheprovisionsoftheSettlementAgreementbutwithoutTrainingCenter
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closures.SinceTrainingCenterratesoftheHHRBudgetbaselinewerefor2012,theIDandDDwaivercostsemployedforTable13werealsobroughtuptothe2012levelsreportedintheHHRUpdatebriefing.Maintainingcurrentlyfundedwaiversfor10yearscosts10timesthecostofmaintainingallthoseonwaiversfor2012.Person-yearsforTrainingCenterresidentsdiminishwithmortalityassuminga
therewouldbenonewadmissions.
Withtheseassumptions,theunderlyingbaselineisapproximately$4.5billionandconsumes87percentofthetotalprojectedbudgetforsupportstothosewithID/DD.Atbest,HHRcouldexpecttosaveonly6percentthroughTrainingCenterclosures.
WaiverrateshavefourtimesmoreimpactonthetotalbudgetthanTrainingCenterrates,evenwithTrainingCentersremainingopen.Thisisbecause80percentofthetotalcostsarefromwaivers,andtotalwaivercostsareproportionaltotheaveragewaiverrate.
2.ImpactofWaiverCostInflation
From2000to2010,IDwaivercostsinflatedatanaveragerateof8.1percentperyear.AlthoughIDwaiverinflationmighthaveleveledoffnow,itismorelikelythatwaiverchargeshavereachedtheircurrentlimitauthorizedbytheGeneralAssembly.RestructuringtheIDwaiverandincreasingsalarycapstocompetitivewagespromisestocontinuethe8.1percentgrowthrate.Thefollowingpointsshouldbeimportanttoplanners:
8.1percentgrowthmorethandoublestheunderlyingrateinthe9years2012to2021.
Accumulatedcostsincrease66percentfortheSettlementAgreementscheduleofnewIDwaivers,$339.5millionmorethanwithouttheinflation.
AccumulatedcostsincreasetheunderlyingbaselineofIDwaiversof$3.3billionby$1.5billion,or46percent.
TotalIDwaivercostsincreaseby$1.9billionor48percentovertheir$3.9billionbaselinewithoutinflation.
ThesenumbersshowthattheimpactofpotentialinflationonjusttheIDwaiverdwarfstheothercostconsiderations.Communitycostsoftheunderlyingbaselinewouldlikelydominatedeliberationsovertheexpansionofwaiverservices,subordinatingTrainingCenterresidentneeds.ThissubordinationislikelyalthoughtheneedsofmostresidentstransitioningfromTrainingCentersintothecommunityhelpedinitiatetherenegotiationsincemostresidentsrequirerestructuringandexpandingIDwaivercoverage.Also,futurecost-containmentmeasuresmightwellplacecapsonservices.Costconstraintswouldfallmostheavilyonthosewiththegreatestneedsandmostvulnerability,includingthosewhohavetransitionedintothecommunity.
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Number'in'
2012
PersonYears'
for'10'Years
Annual'Cost'to'
General'Fund
10Year''''''''''''''''''''
GF'Costs
Percent''''''''''''''''''''
of'Costs
ID'Underlying 8,621 86,210 $3,339,988,387 65%
New'ID SA'Schedule 13,363 $517,696,263 10%
DD'Underlying* 584 5,840 $93,909,600 2%
New'DD SA'Schedule 2,500 $40,201,027 1%New'Family'
SupportsSA'Schedule 37,950 $3,000 $113,850,000 2%
Other'New'Funds'for'the'Settlement'Agreement ($28,600,000) 1%
HHR'Underlying'Baseline'Costs $4,478,514,975 87%
New'GF'for'Community'Waivers'and'Family'Supports $671,747,290 13%
Leverage'of'Increased'Waiver'Rates $4,105,645,277 80%
Leverage'of'Increased'Training'Center'Rates $1,044,616,989 20%
Total'General'Funds $5,150,262,266 100%
HHR'Budget'Net'"Savings"by'Closing'Training'Centers $295,400,000 6%
Training'Center'and'ID'waiver'census:'Quarterly'Report'of'Office'Activities,'DBHDS,'for'Oct.Dec.'2011.''
*DD'Waiver'census:'Virginia'Board'for'People'with'Disabilities'2011'Assessment'(2009'data).
ID'Waiver'cost'of'$75,465:'HHR'briefing'to'Joint'commission'on'Health'Care,'September'18,'2012,
'''entitled,'Update'on'Virginias'Settlement'Agreement'with'the'U.S.'Department'of'Justice
*DD'Waiver'costs'of'$37,768:'Virginia'Board'for'People'with'Disabilities'2011'Assessment'(2009'data)
Family'Supports'annual'cost'from'private'communications.
Training'Center'annual'costs'of'$224,245:'HHR'Update'briefing,'September'2012
Credit'of'$28.6'million'for'the'net'of'additional'cost'requirements
$1,044,616,989 20%
$38,742
$16,080
Training'''''''''
Centers1,018 9,074 $115,124
Table&13.&10+Year&Budget&for&HHR&Underlying&Baseline&and&New&Settlement&Agreement&Requirements&&&&&&&&&&&&&&&&&&&&&&&&&&
3.ValueofTrainingCentersforCostContainment
Thosewiththegreatestdisabilityorchallengingbehavioralissuesarethemostvulnerableandproblematic.Forthem,safetyandmedicalcareconsiderationsmustbeparamountinshapingtheirsystemofsupports.ThesewillalsobethemostexpensivefewinthepopulationofthosewithID/DD,andmanagingthecostsoftheircarehelpscontainoverallcosts.
TrainingCentersofferanalternativemodelforprovidingsupportstothosewithID/DDamedicalmodelratherthanamanagedcaresupportsmodel.PreservationofasignificantTrainingCenterpopulationprovidesabaselineagainstwhichtomeasuretheperformanceofsupportsforthosewiththegreatestmortalityrisk.ComparisonswiththoseonIDwaiverforcostandoutcomescouldrevealopportunitiesforsavingsinthecommunitysystem.
TrainingCentersofferanefficientmeansofprovidingprofessionalstaffsupportstoresidentsandareprobablylessexpensiveforthosewiththegreatestvulnerabilityandmostchallengingmedicalneedsorbehaviors.Asanexampleofaneconomyofscale,TrainingCentersefficientlyusenursingsupport.Asournationfacesanursingshortage,TrainingCenterscanoperatewitha30:1resident-to-nurseratiomadepossiblebyanintegratedteamapproachwithlicensedpracticalnursesfillinginlessdemandingroles.Inthecommunity,grouphomeswithonlyfourbeds,orevensomewhatlargercongregateunits,couldnotprovideon-sitenursingsupportinacostcompetitive
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manner.Costeffectivenursingsupportwouldonlyavailablebyphone,withaboutanhourstraveldelay,orataTraining-Center-likecrisisstabilizationcenter.
TrainingCentersareaplacetotrainstaffanddevelopbestpractices.Internshipsoftenleadtoprofessionalsadoptingcareersinprovidingservices
andothersupportstothosewithID/DD.Opportunitiesforyoungprofessionalstoexperiencethechallengesandrewardsofprovidingcarehelpsrecruitthosewithcriticalskillsataffordablerates.
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AttachmentI:
QualificationsofRobertW.Anthony,Ph.D.Overall, Dr. Anthonys career was devoted to public service working for non-profitorganizations whose missions were to determine whether government programs were
likely to accomplish their intended goals. In his career, Dr. Anthony has been expected toobjectively analyze the broad prospects of program effectiveness that call for a breadth of
background that spans beyond the expertise of individuals managing or conductingspecific programs. Dr. Anthony received his Ph.D. in physics from the University of
Michigan in 1971 and proceeded to apply his analytical skills to studying and forecastingthe unexpected and unintended impacts of technology on society in the applied policy
field of Technology Assessment. Among other studies, Dr. Anthony analyzed the
delivery of social services in rural areas through transportation and communicationtechnologies, public lack of acceptance of nuclear power and waste disposal options, andissues involving multiple stakeholders in the energy and materials sectors. Dr. Anthony
consulted with the Congressional Office of Technology Assessment, testified beforeCongress, as well as worked on competitive research grants won from the National
Science Foundation and other Federal agencies and commissions. From 1982 onward, Dr.Anthony primarily supported the Office of the Secretary of Defense in the oversight of
operational testing of military systems. In these efforts, he evaluated the technological,psychological, and organizational aspects of performance. Key to this was identifying
the critical operational issues, that is, what mattered most to accomplishing the mission.During this period, Dr. Anthony also analyzed counter drug operations and counter
insurgency operations. This work led to an understanding of these clandestinedistribution and attack networks. In addition, he developed and calibrated a model of the
psychology of deterrence with real operational data.