Our question to Secretary Bigby
It was the same story over and over at a public hearing this past Friday, presided over by Secretary of Health and Human Services JudyAnn Bigby.
Speaker after speaker urged Bigby and her panel of EOHHS assistant secretaries and commissioners at the Agganis Arena at Boston University not to cut the budgets of their programs. The hearing room was packed with some 300 people, many of them disabled, and many of them program providers.
Some of those testifying, such as Hang Lee of Multi-Cultural Independent Living Center of Boston and Paul Spooner of the Metro West Center for Independent Living, even urged increased funding for their centers — an additional $1.1 million in each case.
SEIU organizer Stu Dickson (at table) testifies before EOHHS Secretary JudyAnn Bigby at state budget hearing on Friday.
A panel of advocates with the Association of Developmental Disabilities Providers simply asked for the budget cuts to stop. “We ask you to remind the governor (who placed $350 million in the state’s rainy day fund earlier this fall) that it’s still raining,” said Gary Blumenthal, president of the organization. Ten thousand families are without support services from the Department of Developmental Services, among the other results of years of budget cutting, he said.
But it doesn’t seem Bigby will be able to do much to push back against the cuts, much less give Lee and Spooner additional funding, if the governor’s budget people decide to take aim once again, as they’ve done all along, at critical DDS programs. Despite an uptick in state revenues that have brought those revenues back to the levels of Fiscal Year 2008, prior to the nation’s economic meltdown, Bigby stated in a notice sent out prior to Friday’s hearing that:
FY 13 will be challenging and require cuts and reductions and the need for the Administration to make difficult decisions.
Sounds like Administration and Finance Secretary Jay Gonzalez may have already told Bigby to prepare for the worst.
Yet, despite the continuing bad budget news, most of those at the portion of Friday’s hearing devoted to DDS issues still apparently retain the faith that the administration’s plan to close four state developmental centers will somehow rescue them. Several speakers praised Bigby for her efforts to phase down the Fernald, Monson, Templeton, and Glavin centers, apparently hoping that the budgetary “savings” in doing so will be directed to their programs.
Since FY 09, the administration has cut the developmental center line item in the state buget by more than $45 million. But, as I reminded the audience (including Secretary Bigby) when I got my three minutes to speak, we’ve seen no evidence thus far that the community line items have benefited from the cuts in the developmental center account.
Since FY 09, cuts in the community-based accounts include reductions to adult family supports (26.9 percent cut), community transportation (17.6 percent), community day and work (3.8 percent), and Turning 22 (35 percent). As the ADDP has pointed out, direct care workers in the DDS community system haven’t gotten a raise in their relatively meager pay and benefits in four years.
Meanwhile, the list of people waiting for community-based residential care in the state has only grown longer as the administration has transferred residents of the developmental centers to community placements. “Where is the promised expansion of the community system” that was supposed to happen as a result of the developmental center closures? I asked Bigby in my testimony.
Later, I spoke to an EOHHS fiscal executive at the hearing and got no answer to my question from him either.
One of the few at the hearing who understands the extent of the negative impact the developmental center phase-downs have had so far is Stu Dickson, a DDS service coordinator and an organizer with the SEIU Local 509 state employee union. Dickson urged Bigby to restore $5 million to the DDS administrative account, which funds the service coordinators, who arrange for and monitor services for community-based clients.
Dickson later said that despite the ongoing closures of the four developmental centers, DDS has not assigned any additional service coordinators to the community system. The department has repeatedly laid off the coordinators, whose caseloads have grown to nearly unmanageable levels.
Our question to Secretary Bigby and to the opponents of the developmental centers remains: What has the administration done so far, and what will it ever do, to benefit the community system through the developmental center closures?
DDS providers seeking to cut a key lifeline
One of the key functions of the Department of Developmental Services is performed by service coordinators.
Their job is to make sure clients are actually getting the services in the DDS community-based system that are specified in their plans of care and for which the state is paying. They also determine the most appropriate sources of services for clients, based on their knowledge of the clients and available programs in the DDS system.
DDS even relies on these people to help monitor conditions in group homes. During a phone conversation a couple of years ago, the head of the DDS’s group home licensing office stated that service coodinators ensure that every group home in the state is visited at least six times a year and that conditions in them are checked.
DDS Commissioner Elin Howe has called service coordinators “the heart and soul of our agency.” The SEIU state employee union, Local 509, stated that in its collective bargaining agreement with the state, DDS recognizes service coordinators as performing one of the agency’s “most essential functions in the community-based service system.”
Yet, due to repeated budget cuts in recent years, the average caseload for service coordinators has been rising to the point where it is now about one service coordinator to 60 clients. This is more than three times the standard caseload recommended for social workers in this field, according to the SEIU, which organizes service coordinators and other human serivces workers.
At a budget hearing scheduled for Friday (December 9, from 2 to 6 p.m. at the Agganis Arena at Boston University), advocates will plead for more funding for a wide range of community-based line items that have also been cut in recent years. These pleas are coming in the wake of an announcement by Health and Human Services Secretary JudyAnn Bigby late last month that the state budget for the coming fiscal year will probably necessitate further cuts in these programs and that the administration will have to make “difficult decisions.”
But apparently not all of these advocates are rooting for the service coordinators. The Association of Developmental Disabilities Providers has actually suggested that Bigby further cut the DDS administrative line item, which funds the service coordinators. In the last line of a recent email, informing its members of the Friday EOHHS hearing, the ADDP stated:
ADDP will urge any spending reductions to be focused on the state’s own administrative and service system and to protect the more cost effective and inclusive community delivery systems. (My emphasis)
Perhaps the ADDP will respond here to tell us why the service coordinator positions should be cut further and the caseloads should grow even larger. Could it be that the state-funded providers, who in turn fund the ADDP, don’t really want anyone looking over their shoulder and monitoring the services they are delivering or the conditions in their group homes?
In contrast, the SEIU is asking that the administration to restore $5 million to the DDS administrative line item. The SEIU contends that between 2007 and 2010, 82 service coordinator positions were cut, placing Massachusetts in the bottom 10 percent of the country for monitoring and overseeing the provider contracting system and the care it provides. In a statement, the SEIU contended that:
These (service coordinator) jobs more then pay for themselves by promoting skill development and greater independence in the DDS population. Left to their own devices, programs settle for providing ‘custodial’ care which perpetuates a burdensome, wasteful and inefficient expense to state government.
The SEIU last year tried unsuccessfuly to reopen the federal court case that brought about improvements in care in the DDS system since the 1970s, arguing that the cuts in service coordinators at that time were a violation of a key court order that DDS provide sufficient, adequately trained personnel to meet clients’ needs.
The Globe tells half the story about Fernald
A front-page article that ran Thanksgiving Day in The Boston Globe depicts with great sensitivity the lives of four men who were moved out of what was then the Fernald School 40 years ago and have lived ever since in the community.
The problem is that the piece, by Globe columnist Yvonne Abraham, implies that the Fernald Developmental Center of today remains the same over-crowded, poorly run institution that it certainly was for these men when they lived there from the 1950s through the 1970s. At the very least, the story neglects to mention the dramatic improvements that were made in the conditions at Fernald and elsewhere after the federal court assumed oversight in the 1970s of care delivered in Massachusetts to persons with intellectual disabilities.
And the story mistakenly implies that only community-based care is appropriate for the residents of Fernald and other state developmental centers today.
From the all-caps headline (“CELEBRATING THE GIFT OF BEING FREE”) onward, the article paints Fernald unrelentingly as a dark and isolated prison. While that was true up through the 1970s, the untold story is that Fernald and the five other remaining developmental centers in Massachusetts today are state-of-the-art facilities that are highly integrated with their surrounding communities and serve a population that needs their high level of services.
Abraham, however, doesn’t seem to want to discuss that part of the story. At first, it wasn’t entirely clear to me why she portrayed Fernald in such a uniformly negative light throughout the story. Not only is there no mention in the story of the improvements at Fernald since the 1970s, but there’s not even any mention of the fact that Fernald and three other developmental centers in Massachusetts have been targeted for closure by the Patrick administration. Or that guardians of 14 remaining Fernald residents oppose the closure and have kept the facility open for almost a year and a half beyond its scheduled closing date after having filed administrative appeals of the transfers of their wards from the center.
Why not mention all of those things that have been going on at Fernald currently and in recent years and place the story of the facility in a modern day context? It would have been a more interesting story, I think, had Abraham noted the contrast between the four men who are thankful today that they were able to leave Fernald, and the 14 guardians who today believe Fernald is the best place available for their loved ones.
It was only as I was nearing the end of Abraham’s piece that I came across a paragaph that made clear to me what appears to be her agenda. She stated:
The world has caught up with (the four men who left Fernald and a former worker who arranged for their move in 1971 to a group home outside of Fernald.) The goal now is to keep people with disabilities in the community, to help them realize their potential and enrich their surroundings.
Yes, it was now clear that this article was yet another in a long line of journalistic paeans to “community-based” care for people with intellectual disabilities. State-operated institutional care — bad. Community-based care — good. That’s the over-simplified storyline onto which too many journalists seem to feel the need to grasp, while ignoring the subtleties of recent history and even federal law.
Community-based care is the goal for many, but not for everybody. The U.S. Supreme Court, in Olmstead v. L.C., recognized that for some people with the most severe and profound levels of intellectual disability, institutions such as Fernald may well provide the most appropriate care.
Moreover, the community system today does not live up to the utopian ideal that Abraham’s piece sets for it. I’m sure that three of the former Fernald residents in Abraham’s story do live now in a “sweet bungalow” in Hyde Park, and that they do have a “good life,” in which they go to day programs where there is tai chi, singalongs and crafts. I have no doubt that Abraham was struck in spending time with these men by “how much of their potential was squandered” at Fernald 40 or more years ago and by “the joy of the lives they’ve salvaged” in the community.
But while there are many success stories in the community system, that largely privatized system is beset today with widely acknowledged problems of high turnover and poor training of direct-care staff, and abuse and neglect. At the same time, state contracts worth hundreds of millions of dollars held by vendors to run community-based group homes are poorly overseen by the state, resulting in the potential for widespread waste, fraud, and abuse in their business practices. The media in this state have not been covering those issues, but the media in New York State have been. (See this and this.)
We think it is a tragedy that the Patrick administration apparently views care for the intellectually disabled in this same simplistic light of institution-bad and community-good, and is shutting the four developmental centers in budget-cutting moves. We are waiting for the day when the media take a more nuanced view of this issue, and at least recognize that there is another side to the story.
We strongly urge Abraham and other journalists to visit the Fernald, Glavin, Monson, and Templeton Centers, all of which are steadily being emptied of their staff and residents, before it’s too late. They will see for themselves the wonderful level of care that takes place in those centers, and will note that there are no young, high-functioning residents like Albert, Curtis, Richard, and Joe, left in them today.
Funding for DDS clients falling through the cracks
There are few burdens greater than having to care for a loved one with a severe intellectual disability, particularly when the state declines to provide any help.
At a public hearing earlier this week, members of the Legislature’s Children, Families, and Persons with Disabilities Committee heard stories from a number of people whose loved ones have fallen through the cracks in the system.
The Committee is considering a number of bills intended to help people who find themselves just outside of the Department of Developmental Services’ strict eligibility standards, or for whom, there just hasn’t been any funding for community-based residential, day, work, and other programs due to years of budget cuts. There’s some hope that a recent uptick in state revenues will translate into some additional funding of these programs.
Linda Boucher testified that her son attended special education programs from the time he was 3 until he reached the age of 22. At that age, special education services end, and people needing services must apply to DDS, which uses a “rigid” standard to determine eligibility. If a person’s IQ measures above 70, eligibility is denied even if the person has significant problems in adaptive functioning, including very low conceptual, practical, and social skills.
Boucher’s son scored 75 on an IQ test and was denied DDS services. He had been in a day program, she said, but has been home ever since. Boucher has a full time sales job that often requires her to be away from home for as much as 10 hours at a time, and sometimes requires her to be away from home overnight. It’s as if her son is under house arrest, she said.
“Where do I go? I need help,” Boucher said, her voice cracking with emotion. Ironically, Boucher worked in the Department of Mental Health during the Dukakis administration and helped develop many of the community-based programs for persons with intellectual disabilities that are now being cut. She said no one from DMH or DDS will now return her phone calls.
One bill before the Committee (H. 3527 ) would require the DDS to use a less restrictive standard in determining whether a person has an intellectual disability and is therefore eligible for DDS services. The bill would bring the state in line with the American Association on Intellectual and Developmental Disabilities, in establishing eligibility for DDS services for IQ scores of “approximately” 70 or below. This would prevent the rigid cutoff now used by DDS in excluding people from services.
One woman testified that she is concerned she will be forced to quit her job to care for her son, who is now 21 and needs one-on-one supervision. He is not intellectually disabled, his mother said, but nevertheless lacks most social skills. He currently attends a special education facility and is able to hold down a job. But because he is not able to control his behavior, he must be supervised at all times.
Another bill before the Children and Families Committee (H. 983) would provide an additional $23.4 million in funding for DDS community-based programs for persons with special needs who are either turning 22 or have graduated from high school.
However, this bill would also direct that funds from the sale of developmental center properties be earmarked for community-based programs for persons turning 22. We would support that language if the proponents of the bill would, in turn, support the continued operation of the developmental centers for those who choose to live in them. Unfortunately, there’s not much chance of that happening.
It’s not only persons with disabilities who slip through the cracks in the DDS system. There are also the direct-care workers who tend to be underpaid and under-trained, particularly in privately run group homes that operate under contracts with DDS. One bill (S. 45) would establish a state task force to study the average compensation, level of training and turnover of these workers.
Lisa Gurgone, Executive Director, of the Mass. Council for Home Care Aide Services, noted that direct-care workers tend to struggle to make ends meet, and termed those workers “a piece of the puzzle left out of health care reform in Massachusetts.” She and other speakers maintained that with the numbers of elderly and disabled people projected to grow rapidly in coming years, the state needs to develop a new workforce strategy to meet the demand. The task force is a first step in that direction, they said.
One other bill, which COFAR supports, would provide easy public access to a wide range of information about direct-care worker turnover and compensation as well as compensation of top executives of DDS contractors. The bill (H. 975) would require all of that information to be published on the DDS website. (The Arc of Massachusetts, which is heavily funded by DDS contractors, predictably opposes this bill.)
Finally, COFAR strongly supports H. 2683, a bill filed by Rep. Angelo Scaccia, which would establish an independent office of quality assurance that would monitor the care of intellectually disabled persons throughout the DDS residential care system. COFAR has raised a number of questions in recent weeks about the current DDS licensure and certification system for community-based group homes. (The Arc, of course, opposes this bill as well.)
Trying to make sense of DDS’s budget numbers
It’s hard to figure out what to make of the administration’s spending decisions when it comes to providing services to people with intellectual disabilities in Massachusetts.
On the one hand, since Fiscal Year 2009, the administration and Legislature have cut most community-based line items, including adult family supports (26.9% cut), community transportation (17.6%), community day and work (3.8%), Turning 22 (35%).
Not suprisingly, the developmental centers line item in the budget has been cut since FY 09 by $45.4 million, or 24.2%. (In fact, based on a set of numbers provided by the Department of Developmental Services, the budgets of the Templeton, Monson, and Glavin developmental centers alone were cut by almost 70 percent between FY 09 and FY 11.)
Yet, at the same time, the community residential line item (which funds contract-based care in privately operated group homes) has been raised since FY 09 by $182.2 million, or 32%. In addition, the state-operated group home line item has been boosted by $27.4 million, or 19.9 percent, in that time.
These two community residential and state-operated group home line items have been boosted by a total of $209.6 million, while the cuts have totaled $87.4 million during the same period (not counting the planned phase-out of funding under the Boulet lawsuit). The bottom line is the grand total of all DDS line items is $34.6 million higher in the current fiscal year than it was in FY 09.
What exactly has been going on here? We’ve asked DDS for information on where residents of the developmental centers targeted for closure have been transferred. We don’t believe very many residents have opted to live in privately operated group homes. So it remains a mystery to us just why the administration has needed to boost the community-residential line item by more than $180 million.
It’s true there are potentially thousands of people waiting for community-based residential care. But if indeed more than $180 million in new state dollars have been put toward accomodating people waiting for residential services, why has the administration been cutting funds for transportation, day programs, family support, Turning 22 and other programs for those same people?
It would seem that had the administration pared back the increase in the community residential line item to a modest $100 million increase since FY 2009, they could have prevented the cuts in the other community line items at at least held them harmless. It’s strange because the administration’s funding decisions have left it open to the charge from the Association of Developmental Disabilities Providers that the administration has failed to back its “professed interest in Community First,” an initiative intended to boost community-based services choices and spending.
In the meantime, DDS has denied a request by COFAR for records detailing community-based costs of a particular community-based residential program. We’ve been seeking to compare costs and services under this particular contract with the budgets of the Templeton, Monson, and Glavin Centers from FY 2009 to the present. (We don’t believe that the cuts in the developmental center budgets will save money in the long run because these same services must be funded in community-based accounts if they aren’t funded under the developmental center budgets.)
We asked for both a breakdown of the Templeton, Monson, and Glavin budgets and records detailing the costs of medical, nursing, clinical, and therapeutic services provided to residents of the group home program. In a letter dated October 23, DDS’s general counsel stated that the documents we requested concerning the group home program are part of DDS clients’ records and are therefore exempt from disclosure.
COFAR has appealed the denial to the state Division of Public Records, arguing that we are not seeking information that identifies any specific individuals. What we want to find out is which agency or agencies both fund and provide the medical, nursing, clinical, and therapeutic services under this contract, and how much these services cost state taxpayers in total.
We believe DDS can provide the information we are seeking without violating the privacy rights of the individuals in this program. Should DDS refuse to provide this information, the public will have no way of knowing basic details about the provision and cost of these kinds of public services.
Where’s the beef in Community First?
We’ve long maintained that the Patrick administration’s agenda of phasing down and closing state developmental centers would ultimately fail to free up additional funding for the community based system.
It’s been nearly three years since the administration announced its plan to close the Fernald, Templeton, Monson, and Glavin Centers and reportedly plow back as much as $45 million a year in the “savings” into beefing up the largely privatized community-based system of care. That $45 million savings projection was a cornerstone of the administration’s “Community First” initiative.
So far, the administration has succeeded in moving hundreds of residents out of developmental centers, starting with Fernald, which is now emptied of all but 14 of its residents, who have filed appeals of their transfers. But nothing remotely close to the $45 million in savings has materialized. In fact, the opposite has been the case — the administration has continued to cut community-based line items in the Department of Developmental Services budget.
In a November 20 email to members and other advocates, the Association of Developmental Disabilities Providers, which has wholeheartedly supported the closures of the developmental centers, stated the following :
For the last four fiscal years, in order to cope with the effects of the economic collapse of 2008, the Commonwealth’s budget has:
- deeply cut Family Support programs, leaving 10,000 families without service,
- inadequately addressed Chapter 257 rate reform by not introducing sufficient funding to rate making but instead forcing existing programs to redistribute already inadequate funding
- failed to address historically low salary needs of the community workforce (though the Legislature has recently added the first salary reserve dollars in four years)
- continued to require community programs to implement state mandates without sufficient funding, including closing sheltered workshops without funding to replace this model in favor of a more inclusive and empowering model.
- not backed it’s professed interest in Community First and Employment First with funding to make these efforts successful. (my emphasis)
Not exactly a ringing endorsement of the success of the administration’s community-based care delivery model and its promised use of of the savings from the developmental center closures. We hope the ADDP and the Arc of Massachusetts will reach the next logical step in their argument and urge the administration to cease and desist from closing the centers.
Unfortunately, the ADDP and the Arc of Massachusetts are supporting H.984, known as “The Real Lives Bill,” which appears to continue to rely on the premise that DDS clients should not be given the choice of living in developmental centers.
The bill, sponsored by Rep. Tom Sannicandro, is intended to provide for more choice for persons with intellectual disabilities. But it appears to specifically deny consumers the choice of “congregate services.” In other words, everyone should have a choice, as long as they choose only small, community-based settings. We believe, however, that the congregate services provided by developmental centers are appropriate for certain people who are unable to benefit from community based care. And now we’re seeing that closing the congregate care centers is not freeing up community-based funding.
Sannicandro’s bill does appear to recognize that the community-based system has not thus far benefitted from the developmental center phase-downs. The bill’s text reads:
Too many people are not receiving the assistance they need. The public Medicaid system is reeling from cost pressures. The time has come for individuals with disabilities, families, advocates and providers to work together with policy makers in the administration and legislature in crafting a support system that both increases quality and on average reduces costs whenever possible.
We agree with the language in Sannicandro’s bill on that last point. We just disagree that closing the developmental centers is the right way to go about it.
Our questions about the DDS provider licensure system
How effective is the Department of Developmental Services’ licensing and certification system for operators of community-based group homes in Massachusetts?
We reviewed 30 online licensure and certification reports and DDS’s revamped licensure and certification manual. We also reviewed a 2008 licensure survey report by the state Department of Public Health of the state-run Fernald Developmental Center.
Our review found that the federal-state certification process for state developmental centers appears to be significantly more rigorous and comprehensive than the DDS licensing and certification process for state and privately run group homes. This difference would appear to have implications for the relative safety and wellbeing of clients in the widely dispersed, community-based group home system.
DDS licenses and certifies providers that operate more than 2,700 24-hour residential programs in the state, according to figures provided by the department.
State-run developmental centers, which must meet strict federal standards of care, are surveyed by state DPH staff, which follows requirements established by the federal Centers for Medicare and Medicaid Services. The community-based group homes are surveyed by staff of the DDS’s Office of Quality Enhancement, supplemented by volunteer surveyors.
Here are some of our findings. (Additional information about our review can be found in the October 2011 issue of The COFAR Voice):
- Under the DDS’s licensure and certification process for group home providers, only 25 percent of those group home sites are inspected or surveyed by licensing staff during each two-year licensing period. This means that a provider can receive a two-year license to operate even though 75 percent of its homes were not inspected.
- While two of the licensure survey reports we sampled contained detailed findings of deficiencies in care and procedures in the providers’ group homes, the majority of the reports appeared to focus on whether the providers were working to achieve broad and often vaguely worded goals such as “maximizing independence” and “supporting people to live healthy and active lives.” One of the most frequently cited problems in the licensure reports was the makeup of the providers’ human rights committees, whether they had bylaws, and how frequently they met.
In contrast, the 2008 survey report on the Fernald Center contained 56 pages of detailed findings about treatment and care, based on direct observation by surveyors as well as on resident records. Observed injuries were noted in the CMS-DPH report, as well as direct observations that certain residents were not receiving adequate treatment.
While the Fernald Center had some 180 residents in 2008, many of the group home providers whose reports we reviewed provided services to that many or more individuals in their individual networks of group homes.
- Few of the DDS provider reports, most of which were only a few pages in length, appeared to mention the results of direct observations about the care provided to individuals in the residences. None of the reports contained findings of observed signs of injuries to residents or of abuse or neglect. Yet, the state’s Disabled Persons Protection Commission receives some 1,500 complaints of abuse and neglect each year in the community system, more than one third of which are substantiated, according to agency figures.
- In many cases, the DDS licensure surveyors appeared eager to say positive things about the providers, but even those statements usually did not refer directly to observed care issues.
For instance, the DDS licensure report for Fidelity House, Inc., stated that a “remarkable” example of “the way people were valued in their homes” was that “confidential records had one page profiles which carefully described each individual in the first person.” In a number of cases, the survey reports contained the vague statements that the particular provider being reviewed “takes great pride” in its programs or facilities or, in one case, that the provider’s services were “founded upon a values-based mission.”
- All of the DDS provider reports reviewed indicated that the providers were granted licenses to operate, even in the relatively rare cases in which potentially serious problems were cited. In one case, a provider, Behavioral Associates of Massachusetts, was given a one-year conditional license to continue operating even though the license survey found that only two out of six required “quality of life areas” had been achieved. Among the problems noted by the surveyors were that residents’ confidential records were altered and that the provider’s day program was inappropriately operating in the basement of one of the residences.
In another case, the Center for Human Development received a two-year license to operate even though there had been three instances in the previous two-year licensing period in which reportable incidents of abuse or neglect in its residences had not been reported to the Disabled Persons Protection Commission as required.
In October 2010, the Kennedy Donovan Center received a recommendation for a “deferred license” for its residential services after failing to meet the standard on 20 indicators of care and services. The surveyors found that residents in six different group homes had gone more than a year without a physical exam, with two residents having gone 18 months and two having gone 17 months without an exam. One resident who didn’t have a dental exam for more than two years was later was found to need several fillings and extractions, the report stated. Another resident, who had had pneumonia was not provided with a follow-up review by a physician.
A deferred license means the agency can continue operating, but has 60 days to correct the problems. There was no information online to indicate whether those corrections were made.
- Of the 30 online reports surveyed, fully one third were out of date on the DDS website, some by as much as two years. It wasn’t clear whether the DDS has simply been slow in posting licensure reports on its website or whether the licenses may have expired for some of the providers reviewed.
- The DDS licensure and certification procedure was revamped in July 2010, based on input from the providers themselves. In 2009, the Association of Developmental Disabilities Providers stated that it was working with DDS to revamp the licensure system and that it was seeking to reduce the number of group home sites surveyed and the time spent surveying in each location.
Among the changes made by DDS in 2010 were a reduction in the licensure survey time spent in group homes from one to two weeks down to 5 working days, according to the online licensure manual.
- Both the old and revamped reports did not always specify the total number of clients served by each provider or even the total number of group homes run by the provider. Some reports listed all relevant indicators while others didn’t.
We plan to bring our findings to the attention of state legislators who deal with DDS issues, many of whom may be unaware that there is any difference in the state’s oversight of developmental centers and community-based care settings. The claim that the community system provides equal or better care than the developmental centers doesn’t mean much if the oversight of the two systems is not equal.
Another forgotten cost of closing developmental centers
One of the costs of closing developmental centers for the intellectually disabled, which rarely gets considered in budgetary “savings” analyses, is the cost to affected communities in lost economic activity, jobs, and tax revenues.
Two studies done in Kansas and Illinois have each projected economic impacts of tens of millions of dollars annually on local communities in closing a developmental center in each state. We have yet to locate such a study in Massachusetts, even though the Patrick administration has targeted the Fernald Developmental Center in Waltham, the Glavin Regional Center in Shrewsbury, the Templeton Developmental Center, and the Monson Developmental Center in Palmer for closure by the end of the coming fiscal year.
Developmental centers provide both direct economic benefits to their surounding communities from employee salaries and so-called ripple or multiplier effects. Ripple effects include “indirect” sales and jobs in area businesses such as food distributors and office supply firms that provide goods and services to the developmental centers. And those ripple effects include “induced” sales and jobs supported by the developmental center employees when they patronize restaurants, gas stations, banks, grocery stores, computer stores, convenience stores and much more.
An August 2011 report to the Illinois Department of Human Services by the Institute of Government and Public Affairs at the University of Illinois concluded that closing the Jacksonville Developmental Center in Jacksonville, Ill., would affect 591 jobs and have a ripple effect on $47 million of economic activity in Morgan County and $17 million in the city of Jacksonville.
In addition, according to the University of Illinois report, the closure of the Jacksonville Center would result in $590,000 in lost state sales and income taxes paid by employees who were laid off and by suppliers to the facilities.
A September 2009 report prepared for the Greater Topeka Chamber of Commerce on the impact of the Kansas Neurological Institute on the economy of the Topeka area during Fiscal Year 2010 found a direct economic impact of $28 million from the developmental center and an additional ripple effect of $37 million. Taking into account the KNI’s 570 workers, the developmental center supports a total of 1,311 jobs in the local community, the report said.
The KNI report, written by Impact DataSource, a Texas-based economic consulting and research firm, added that the Kansas developmental center generates some $447,000 a year in local sales taxes and $3.3 million in local property taxes.
In testimony last February to a Kansas legislative committee, Christy Caldwell, a spokeswoman for the Topeka Chamber of Commerce stated:
If the motive for closing KNI is saving the state dollars, we respectfully ask your very careful consideration of whether there will be real cost savings. We ask that you consider the economic impact on Topeka; a significant loss for this community, should there be closure.
In Massachusetts, a Department of Developmental Services working group recommended in 2002 that prior to closing any developmental centers, DDS undertake an analysis of the multiplier effect of the closures on the local economies. The working group also recommended consideration of other factors, such as the community use of the facility and the grounds, cost implications of the use of facility space by other government agencies, projected mothballing costs, and projected “ramp-up” costs for new community programs.
We’ve checked with state legislators in whose districts the Fernald, Templeton, Glavin, and Monson developmental centers are located, and with local chambers of commerce, and haven’t yet found any such economic impact studies done of the potential closures of the facilities. We’ve filed a Public Records request with DDS, asking for any such analyses that may have been done.
The University of Illinois study noted that in additional to quantifiable economic impacts of the Jacksonville center’s closure, there are many less quantitative impacts such as the effect on charitable contributions – both time and money – by the facility employees and the impact of the re-location of facility employees and their families on school district enrollments. “All of these more qualitative impacts contribute to the fabric of the local community and may be valued just as highly – even if they are more difficult to measure,” the report stated.
There is, of course, the question whether the loss of economic benefits from the closures of the developmental centers might be outweighed by the potential for reuse of the properties. But those benefits in reusing the properties are largely speculative compared with the concrete benefits provided by the developmental centers themselves. Caldwell stated in her testimony that the previous closure of the Topeka State Hospital “did not garner the private interest and investment (in the former hospital land) that many believed could be gained when the facility closed.”
In addition to undertaking economic impact analyses prior to closing the four developmental centers in Massachusetts, policy makers in this state should reassess the value of the properties involved and what they could reasonably expect to receive for those properties, given the current state of the economy.
One way to avoid cutting Medicaid
The Patrick administration’s “Community First” approach to caring for people with intellectual and other disabilities depends on a huge, $2.6 billion, state and federally funded network of nonprofit contractors.
Many of these contractors or providers are excellent; but, all too often, we hear about cases of abuse, neglect, mismanagement, and fraud, such as the allegations this past weekend by Attorney General Martha Coakley that Adlife Healthcare and three other companies had bilked the state’s Medicaid program out of $10 million.
Adlife Healthcare would seem on the surface to be a shining example of the Community First approach. The company’s website states that it tailors its health care programs for disabled persons in a manner that “maximizes the client’s independence and dignity.” The program, the website states, allows clients to remain in the “familiar comfort” of their own homes, and begins with a visit from a registered nurse who then arranges for services from additional nurses, physical therapists, case managers, and home health aides.
All well and good, except that, as Coakley alleges, Adlife charged Medicaid for services without having provided them, including billing for people who had died. Ultimately, the company over-billed the state by $5.5 million, according to Coakley.
Medicaid, which is one of the state’s largest sources of budgetary spending, funds a wide range of services, from health care for both low income families to care and services for persons with intellectual disabilities in both the state developmental centers and community-based system. Because of its sheer size, Medicaid nationally is likely to be a source of at least $1.2 trillion in revenue cuts that the “super committee” in Congress is required to recommend by November.
But there are experts around who argue that a significant portion of those cuts would not be necessary if the state and federal governments did a better job in preventing and detecting the kind of fraud that providers such as Adlife are accused of perpetrating in the Medicaid system.
In his 1996 book, “License to Steal: Why Fraud Plagues America’s Healthcare System,” Malcolm Sparrow maintains that if the health care industry:
learns the art of fraud control, then the industry will have learned a discriminating way to save money — by investing in the capacity to distinguish between legitimate and illegitimate claims. The alternative is to use less discriminating methods, such as across-the-board reductions in benefits, further restrictions on eligibility, or lower reimbursement rates for providers.
State Auditor Suzanne Bump has reportedly decided to follow Sparrow’s advice. According to The Globe, she plans to intensify her office’s focus on Medicaid fraud and has appointed a former federal prosecutor to head those investigations. One Medicaid fraud expert told The Globe that most Medicaid fraud is perpetuated by “providers who take advantage of loopholes in regulations to process claims that would be detected by more rigorous analysis.”
Last week, COFAR President Tom Frain and I met with three members of Bump’s staff, to urge them to investigate the state’s human services provider system, particularly the contracting network funded by the Department of Developmental Services. We hope Bump’s intensified focus on Medicaid fraud will include the DDS contracting system.
We fully support the community-based system of care in Massachusetts; but as the Adlife and too many other examples show, it is a system that is all too vulnerable to waste, fraud, and abuse and needs much better governmental oversight than is currently the case.
COFAR blog 