Delivery of Care

Warning: drastic budget measures ahead

The state budget crunch may result in reduced services and waiting lists for Rhode Islanders with developmental disabilities

Photo by Anne Peters

Rebecca Boss, the director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals prepared a corrective action plan to deal with overspending in the current fiscal year.

By Gina Macris
Posted 12/11/17
The corrective action plan proposed by Rebecca Boss, the director of the R.I. Department of Behavioral Healthcare, Development Disabilities and Hospitals, to address budget deficits in the current fiscal year, could result in reduced services for developmentally disabled Rhode Islanders, in potential violation of the federal court consent decree.
Will lawmakers take into account that for every dollar in state revenue that is reduced, individuals with developmental disabilities also will lose a little more than a dollar in federal Medicaid funds? Is there a way to provide greater oversight about what is happening at BHDDH in terms of operational priorities? Will the state budget for health and human services become a political football in the 2018 gubernatorial election?
There is a tendency, at the state and national level, to demean those who need benefits and services as somehow being unworthy of receiving them, compared to the rich and the wealthy, as if status was pre-ordained.
In defending the tax cut legislation pending before Congress, Iowa Sen. Chuck Grassley said, in reference to the proposed elimination of the estate tax, “I think not having the estate tax recognizes the people that are investing, as opposed to those that are just spending every darn penny they have, whether it’s on booze or women or movies.”
In contrast, Eric Beane, the secretary of the R.I. Executive Office of Health and Human Services, said in prepared remarks before the Dec. 5 Senate Finance Committee hearing: “When we discuss overspending across our agencies, context is important,” according to reporting by WPRI’s Ted Nesi. “It’s rescuing a child from neglect and abuse. And it’s working with a person with developmental disabilities to ensure they have every opportunity to succeed.”

PROVIDENCE – Rhode Islanders with developmental disabilities would face “drastic measures,” such as waitlists for services or reductions in the amounts the state pays private organizations providing these supports, if their funding agency must resolve a sizeable budget deficit by the end of the fiscal year June 30.

Rebecca Boss, director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), reached that conclusion in a Nov. 30 letter to the director of the state budget office and the finance committee chairmen of the House and Senate.

Boss pledged to keep working “to minimize the anticipated disruptions and destabilization that would result from such measures on our vulnerable populations.”

In the last several years, the R.I. General Assembly has covered BHDDH deficits with supplemental funding.

Boss' letter outlined a corrective action plan for reducing the deficit, an estimated $15.9 million in state spending, including about $12 million from developmental disabilities programs and nearly $4 million from the Eleanor Slater Hospital. Without a state match, roughly the same amount in federal Medicaid dollars also would evaporate.

The corrective action plan described a variety of cost-cutting initiatives that, at best, would address less than half the overall shortfall, but Boss’s letter did not add up the total savings. BHDDH officials were not able to respond immediately to several detailed questions about the corrective action plan.

Corrective action budget plans
Corrective action plans are required whenever a state agency runs a deficit. But the BHDDH plan raises questions about its future ability to comply with a 2014 federal consent decree that requires Rhode Island to integrate adults with developmental disabilities in the community to comply with the Americans With Disabilities Act [ADA].

Integrated services, which require small staff-to-client ratios, are inherently more costly than the segregated, facility-based programming Rhode Island has used in the past, in which one person can keep an eye on larger groups of people gathered in one room.

An over-reliance on sheltered workshops and day centers put Rhode Island in violation of the ADA's integration mandate as spelled out in the Olmstead decision by the U.S. Supreme Court, according to findings of the U.S. Department of Justice.

Never in complete compliance
Rhode Island has never been in complete compliance with the incremental integration goals of the consent decree. In the spring of 2016, the state came close to being held in contempt of court over lack of funding, among other issues. Since then, as long as the state has put additional money and professional expertise into efforts to improve services, it has avoided sanctions.

Most recently, during a U.S. District Court hearing on Nov. 30 – the same day Boss turned over her corrective action plan – the judge in the consent decree case repeatedly brought up his concerns about money to fund the services required by the consent decree. Judge John J. McConnell, Jr., said he would be keeping an eye on the budget process, both at the state and federal levels. [See link to ConvergenceRI story below.]

What the corrective plan entails
The BHDDH plan proposes returning to the state a $2 million balance in funds that had been allocated to a performance-based supported employment program that responded to a court order to help more adults with developmental disabilities find jobs.

In her plan, Boss said that BHDDH would continue to provide funding for supported employment. Anecdotal information from providers and families has indicated that, even with the performance-based program, employment services have not been available to all who wanted them.

Boss, meanwhile, outlined other potential cost savings. She said correcting errors in the needs assessments of 46 adults with developmental disabilities would result in $400,000 in savings, once the individual funding authorizations for those persons are reduced.

Because of widespread complaints that the original assessment shortchanged individual needs, resulting in routine awards of supplemental funds, BHDDH adopted an updated version of the standardized interview about a year ago that was said to be more accurate.

The newer assessment contributed to higher per-person costs that are reflected in much of the $12 million projected deficit in developmental disabilities, Boss said. The 46 errors in assessment occurred because interviewers did not correctly utilize a certain group of questions in the new interview process, she said.

At the start of the current fiscal year in July, with rising costs from the new assessment already apparent, BHDDH imposed stringent health and safety standards for awarding supplemental funds on appeal.

Following the money
Of the $12 million projected deficit in developmental disabilities, $4 million is related to “various” cost-cutting initiatives in the current fiscal year, which BHDDH does not expect to achieve, Boss said.

She did not describe these unachieved savings in any detail, except to attribute $500,000 to the department’s inability to move residents out of three of five state-run group homes that had been scheduled to close.

The remaining two homes are special care facilities that are being consolidated and will close, Boss said. She has said such special care facilities do not comply with a new Medicaid Final Rule on Home and Community-Based Services.

In the last quarter of the fiscal year, beginning April 1,2018, BHDDH plans to cut the daily reimbursement rates for residents of group homes with relatively mild developmental disabilities, those assigned to the lowest two levels [labeled A and B] of a five-tier funding scale. This measure is expected to save $200,000.

Additionally, BHDDH has a “continuing commitment” to reducing the population of group homes by 110 during the current fiscal year, which would bring an estimated savings of $900,000, Boss said. She did not elaborate; whether or not such a reduction is a realistic projection remains unclear.

Increasing costs
In Rhode Island, the primary alternative to group homes is shared living, in which a person with a developmental disability lives with a family in a private home.

During the 27 months between July 1, 2015, and Sept. 20, 2017, the number of individuals in shared living increased by 92, according to BHDDH figures, from 268 to 360.

The breakdown includes 40 in the fiscal year that ended July 1, 2016, 38 in the fiscal year that ended July 1, 2017, and 14 in the first three months of the current budget cycle.

At the Eleanor Slater Hospital, all but $900,000 of the nearly $4 million shortfall can be attributed to salaries and benefits, including $2.1 million in overtime, Boss said in her letter.

The hospital has faced numerous problems, most critically a preliminary report from the Joint Commission in September that signaled Eleanor Slater would be denied accreditation because of unsafe facilities. The report prompted an increase in staffing so that patients are checked every five minutes.

BHDDH plans to move patients out of the substandard facilities, but that consolidation is far behind schedule.

Gina Macris, a frequent contributor to ConvergenceRI, writes for the Developmental Disability News. [olmstead-ddnews.org]

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