Full Cost Analysis of HHR-DBHDS Budget FINAL

7/30/2019 Full Cost Analysis of HHR-DBHDS Budget FINAL

1/29

1

PreliminaryAnalysis

oftheHealthandHumanResourcesBudget

fortheSettlementAgreement

RobertW.Anthony,Ph.D.*

MemberoftheBoardParents&AssociatesoftheNorthernVirginiaTrainingCenter

December4,2012

*Dr.AnthonysqualificationsarefoundinAttachmentI.


2/29

2

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.

.


3/29

3

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


4/29

4

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.


5/29

5

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.


6/29

6

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


7/29

7

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.


8/29

8

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


9/29

9

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.


10/29

10

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


11/29

11

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.


12/29

12

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.


13/29

13

Year Census FatalitiesNew/

WaiversCensus Fatalities

Old/


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


14/29

14

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


15/29

15

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.


16/29

16

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.


17/29

17

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.


18/29

18

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.


19/29

19

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.


20/29

20

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.


21/29

21

Year Census FatalitiesNew/


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.


22/29

22

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.


23/29

23

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.


24/29

24

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.


25/29

25

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


26/29

26

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.


27/29

27

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


28/29

28

manner.Costeffectivenursingsupportwouldonlyavailablebyphone,withaboutanhourstraveldelay,orataTraining-Center-likecrisisstabilizationcenter.

TrainingCentersareaplacetotrainstaffanddevelopbestpractices.Internshipsoftenleadtoprofessionalsadoptingcareersinprovidingservices

andothersupportstothosewithID/DD.Opportunitiesforyoungprofessionalstoexperiencethechallengesandrewardsofprovidingcarehelpsrecruitthosewithcriticalskillsataffordablerates.


29/29

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.

Full Cost Analysis of HHR-DBHDS Budget FINAL

Documents

Transcript of Full Cost Analysis of HHR-DBHDS Budget FINAL