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April 18, 2005
First Interstate Bank (Heritage Room), 222 South Gillette Avenue
Gillette, Wyoming
Representative Elaine Harvey, Chairman
Senator Hank Coe, Vice Chairman
Senator John Hines
Senator Mike Massie
Representative Bruce Barnard
Representative Rosie Berger
Representative John Hastert
None
Don Richards, Senior Research Analyst
Please refer to
Appendix 1 to review the Committee Sign-in Sheet
for a list of other individuals who attended the meeting.
Chair Harvey called the meeting to order at 8:03 a.m. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Minutes from the November 22, 2004 Select Committee meeting were approved without change.
Chair Harvey initiated the meeting by providing a synopsis of the Select Committee's charge found in the authorizing legislation, 2004 SF 84 ('04 Laws, Ch. 104). In particular, she directed the attention of members to the two charges of the Committee: (1) to study of the state's programs for the developmentally disabled and to identify opportunities for improvement and (2) to oversee a study to identify the costs of services and a mechanism for funding services for developmental health and education services for preschool students. Chair Harvey also summarized the activities of the Select Committee during the 2004 interim and noted the recommendations of the Committee from its report to the Legislature and the Governor on September 30, 2004.
Dr. Linda Goetze of the Early Intervention Research Institute at Utah State University provided the Committee an overview of the status of her evaluation of preschool services and costs (see Appendix 3). Dr. Goetze explained that initially the family consent forms required by the study were to be collected without assistance from or participation of preschool service providers. Due to low responses, Dr. Goetze subsequently revised the system for obtaining family consent forms. In the revised process, consent packets, along with strategies for obtaining responses, were sent directly to Regional Service Provider for distribution to parents. Dr. Goetze also personally solicited family consents during site visits. As of April 15, 2005, 425 of the target 547 consents had been collected. After inquiries from Representative Berger stressing the importance of obtaining input, Dr. Goetze indicated the campaign would continue, including enhanced incentives for participation, if necessary, or more personal contact on her part.
Dr. Goetze also reported to the Committee that the structure of the Time Diaries articulate in her proposal had been amended to respond to provider concerns and the fact that the end of the traditional school year is quickly approaching. Specifically, providers are being asked about what a "typical" time period of services entails. She indicated the vast majority of providers preferred this alternative method of data collection.
In terms of site visits, Dr. Goetze reported visiting all regions with the exceptions of Region 4 (Teton and Sublette counties), Region 6 (Fremont county), and Region 14 (Wind River Reservation). In order to obtain additional contextual data, Dr. Goetze indicated that further site visits would continue, including revisiting some regions. She reported some difficulty in obtaining statewide data on such things as CHIP [Children's Health Insurance Program] enrollments and sources of referral. Based upon the completed site visits, Dr. Goetze also reported that the capital facilities and the methods of financing such facilities vary widely.
With respect to regional interviews, Dr. Goetze reported that each regional board tends to provide relatively broad discretion to the regional directors, once hired. She did contrast Wyoming's decision to provide services to 3-5 year-olds through a system of non-profits under the Wyoming Department of Health (WDH), while most states provide these services through school districts. On the state-level, Dr. Goetze noted the sizeable turnover in the WDH and lack of historical programmatic knowledge. She added that the longer serving regional directors had been able to provide this context, where lacking.
Dr. Goetze concluded her presentation by indicating the literature review for the study, as stated in her proposal, had been subcontracted to Rutgers University.
Dr. Goetze stated that she hoped the final product could be the result of an iterative process of Committee review of drafts prior to submitting a final report. The Committee discussed this issue and received this suggestion favorably. Senator Hines asked to receive available materials, in writing, in advance of any future meeting so that members would have an opportunity to review and consider them prior to any presentation.
Senator Massie inquired as to what a potential finance mechanism might look like from Dr. Goetze's point of view. Dr. Goetze explained her vision was for a cafeteria approach. In terms of specifics, Dr. Goetze offered a few examples: First, other employers, e.g., school districts, could be included as comparators to demonstrate marginal costs of different employee benefit packages. Second, Dr. Goetze explained she would be able to identify the value of capital donations, as well as capital shortages throughout the state. She indicated that one option might be to devise a grant program that would still provide an incentive for entrepreneurship. Finally, by looking at best practices, Dr. Goetze indicated the ability to look at other states and identify to what extent services are provided and at what additional costs.
The Committee concluded Dr. Goetze's presentation with a discussion of when preliminary data and explanation would be available for Committee review. Dr. Goetze indicated that a draft might be ready as early as mid to late August, certainly by September 1, although some assessments would continue to be done in August. Dr. Goetze stated the survey and data regarding families, costs, and providers would be completed in the next three to four months. Chair Harvey indicated that the Committee should consider an August meeting.
Kathleen Orton, Child Development Service of Wyoming (CDS), testified that as the umbrella organization for all preschool service providers, the providers were looking forward to the results of Dr. Goetze's study. She reported that Dr. Goetze had been very accessible to the regions. Ms. Orton did express some cautious feelings about what the outcome of the study would show. Specifically, Ms. Orton echoed concerns over obtaining the appropriate number of family consent forms and explained that issues such as privacy may deter participation. The alteration of the time diaries was viewed positively by CDS. She also expressed the need for on-going discussions in measuring the progress of children and what appropriate measurement tools should be used. Ms. Orton asked that the costs to screen 3,000 (later corrected by Senator Massie as 8,000) children should be properly accounted for, even if only 2,600 children ultimately receive services.
Finally, Ms. Orton raised the issue of federal funding streams. She indicated that due to recent decisions by the State Department of Education (SDE), federal "Section 611" funding in the amount of approximately $189,000 might not be passed on to the developmental preschools in 2005, as had been the case in the past. She reported learning last August that SDE had indicated certain "discretionary" federal funds would no longer be directed to the preschool service providers.
Tammy Cox, Deputy Superintendent for Special Programs, SDE, and Stephanie Weaver, Fiscal Officer, SDE came forward at the Committee's request to explain the position of SDE with respect to the distribution of Section 611 funds. Ms. Cox presented a letter from Superintendent Blankenship to the Select Committee on this topic (see Appendices 4A and 4B). Ms. Cox and Ms. Weaver explained that after discussing the federal and state law with the Attorney General's staff and SDE internal counsel, SDE determined that all "discretionary" funds had been provided to preschools in addition to what amounts were required by law. Ms. Cox testified that all of the provisions of W.S. 21-2-705 and of federal law are being met without the distribution of the "discretionary" funds. Ms. Cox explained that federal funds are allocated using three components: base, population, and poverty. The Developmental Disabilities Division (DDD), which meets the definition of an "intermediate education unit" receives funding from the SDE and passes those funds along to developmental preschools. She added that due to a change in federal law in the late 1990s, developmental preschools are not allowed to obtain the population payment component because the federal law bases the population payment on elementary and secondary school students only. Ms. Cox testified that it is the position of the SDE to serve children from three to five years old but that nothing in state or federal statute requires the distribution of the discretionary funds to preschool providers.
Senator Massie indicated that in most states the department of education administers preschool services, but in 1989 the Wyoming Legislature designated DDD as the administrator of the program. He indicated that a change in the federal rules governing the distribution of federal funds in the late 1990s treated Wyoming differently due its administration structure for preschools. He indicated that he and Senator Scott addressed the treatment of Wyoming under the population component of the federal formula by passing state legislation. However, he noted that state statute only covers Section 619 funds, not Section 611 funds. He indicated there had been an informal agreement between the preschool providers and SDE. The agreement allowed the preschools to receive an amount of discretionary funds since 2000.
Senator Massie moved to direct LSO staff, working with the Attorney General's Office, to draft legislation to clean up state statutes to allow preschool providers to receive a larger share federal of Section 611 funds to account for the restrictions in the federal formula.
Senator Coe asked what the level of Section 611 funding would be for 2005, consistent with the distributions shown in Table 1 of Appendix 4B. Ms. Weaver indicated that the 2005 amounts were not yet available, but she projected that they might be in the range of 8 to 12 percent higher than 2004 receipts.
Representative Barnard asked what brought on SDE's change in philosophy. Ms. Cox responded that the informal arrangement of providing discretionary funds to the preschool centers had never been in law, and it was not clear to SDE how the distribution of discretionary funds distributed to the preschools had been historically determined. Senator Massie explained the SDE received about $23 million in federal funds in 2004 for these purposes and that the distribution to preschools had attempted to keep an even flow of funds from year to year.
Ms. Cox stated that the SDE wants to support the 3 to 5 year-old population and that the SDE desires to be at the table for these discussions. The cost study being conducted will also play into how direct services are provided to kids. Ms. Weaver added that the federal 611 funds are to serve ages 3 to 21 not just 3 to 5 year olds. Ms. Cox also indicated that SDE could offer assistance to Dr. Goetze's study of preschool costs.
Chair Harvey inquired whether SDE plans to create preschools that serve children with disabilities, and Ms. Cox replied there was no intention of doing so at this time.
After the Committee discussed whether draft legislation was needed at this time or additional research would be helpful first, Representative Hastert seconded Senator Massie's original motion. Chair Harvey re-stated the motion to direct LSO staff to report (a) a concise historical outline of the federal funding distribution, (b) proposed solutions, and (c) draft legislation to include higher 611 funding in the distribution to preschools. Materials should be prepared for the Committee's review in advance of the Committee's next meeting. The motion carried unanimously.
Cliff Mikesell, Administrator, DDD; Ginny Mahoney, COO, WDH; Chris Newman, Deputy Administrator and Program Integrity Manager, WDH, and Iris Oleske, State Medicaid Officer provided the Committee a broad outline of the Division's activities over the last several months (see Appendices 5 through 10).
Waiting Lists. Mr. Mikesell explained that largely because of the 2005 budget footnotes to the WDH budget, which limit transfers out of DDD to other Divisions, the Division was able to completely address the outstanding client waiting list for all three waiver programs. (See Appendix 5A for a table summarizing the waiting list movements in early 2005 and Appendix 5B for a table summarizing the causes of injuries to adult brain injury (ABI) clients.) He added that the average costs of clients coming off the waiting list were less than the average costs of clients already receiving services. He suggested that this phenomenon was, in part, due to the fact that DDD had previously been funding emergency cases first, leaving less severe cases on the waiting list. Mr. Mikesell testified that the Division does have approximately 100 client applications in process and that roughly 80 percent of those might be deemed eligible for waiver services after Division review.
Mr. Mikesell stated that in order to eliminate the waiting list along with the forecast of 25 potential emergency cases, WDH is projecting 99 percent of the Division's budgeted funds will be used. He described this as walking a tight budget rope. While the WDH is hoping it will not have to start a new waiting list, there is a risk factor inherent in the Division's planning. Specifically, the Division is relying on historical underutilization of individual budgeted amounts (IBAs), e.g., children waiver clients tend to use about 80 percent of their IBAs. He indicated that the underutilized portions of the IBAs are now being budgeted for other clients. Concluding on this issue, Mr. Mikesell indicated that this change of funding will certainly have an impact in the 2007-08 budget, since the funding for the newly served clients will be doubled for the biennium. Later, Senator Hines inquired if there had been any difficulty in finding sufficient service providers for the additional clients coming off the waiting list. Mr. Mikesell responded that while there were certainly concerns, no client had been turned down.
New Waiver Opportunities. Mr. Mikesell briefly discussed new waiver possibilities that would allow more self-direction for DD clients (see Appendix 6). In response to questions about who would likely apply for the new waivers, Mr. Mikesell predicted few clients on the existing waivers would likely switch to the new waivers, despite some additional choice. He felt it was more likely that the new waivers would act as an alternative to a waiting list.
Restructure of Fiscal Services. Ginny Mahoney described the new fiscal services structure of the WDH. She explained that Bob Peck is the Department's CFO, and he oversees the Department's Fiscal Services Office. Reporting to Mr. Peck is Dr. Greg Gruman, Director of the Office of Healthcare Financing. Additionally, the Medicaid, Kid Care, Pharmacy, and Program Integrity Offices each report to Dr. Gruman. Ms. Mahoney explained that along with the redesigned structure, each program has a designated fiscal person and those individuals feed information into the divisions and then to the department fiscal offices.
New Rules and Role of Area Resource Specialists. Chris Newman testified that WDH has been diligently working on establishing new rules for the adult home and community-based waiver (see Appendices 7A and 7B). Ms. Newman explained the timeline for adoption of the new rules and indicated that the rules for the child and ABI waivers would not be initiated until the public comment period for the first draft of the adult waiver rules is complete. Ms. Newman suggested that one area the Department is open to Select Committee guidance on is the role and parameters of case managers. Chair Harvey then explained the Select Committee's deliberations on this topic last year, along with the need to maintain choice.
Next, Ms. Newman explained that the roles and responsibilities of the Area Resource Specialists (ARS) had been divided into Area Resource Specialists and Survey/Certification staff. Each would be responsible for different activities (see Appendix 8). Ms. Newman stated that the ARS are not "team members" in determining client plans but that the link between the team and the ARS continues to be important. Ms. Newman explained that there are currently nine ARS serving 1,800 clients. Due to the high workload, she explained that ARS do not attend all meetings but focus on funding in excess of IBA amounts. Mr. Mikesell added that waiver specialists also review plans for consistency, and in the event of extraordinary expenses, WDH has established an Extraordinary Care Committee for additional review. When asked about the members the Extraordinary Care Committee, Mr. Mikesell indicated that the members are the Director of the Office of Healthcare Financing, the Division administrator, and the Department CFO, or their designees. Typically a waiver specialists serves on the Extraordinary Care Committee. He stated that there was a need to try to find a balance by adding individuals from the fiscal side in the decisions –an inclusion that was previously absent.
Navigant Cost Study. Mr. Mikesell presented the results of a contract study on waiver services costs, adding that he had not been involved in the study design (see Appendix 9). He directed the Select Committee's attention to page 10 for a list of the conclusions and recommendations. He stated that numerous data collection issues had been identified during the course of the study and that the analysis of the ABI and children's waiver had been dropped. Mr. Mikesell indicated that other data quality issues remain.
Mr. Mikesell did indicate that the services that account for the majority (about 80 percent) of the expenditures, i.e., day habilitation, and residential habilitation, merit the bulk of any evaluation. He indicated that the study showed 97 percent of the service costs were covered, which leaves a 3 percent shortfall. Representative Barnard inquired whether the providers are paid enough for their work. Mr. Mikesell responded that he believed the study shows that providers are under funded, but the study does not say whether the costs are appropriate and discussed some variability among providers. Mr. Mikesell also stated that future studies would benefit from better architecture. Representative Berger asked if DDD intended to devise a review form in the future to address concerns over the lack of data. Mr. Mikesell responded that he would eventually like to see that in the rules, referencing South Dakota, which uses a funding model similar to Wyoming's DD funding model, DOORS. South Dakota reportedly has quite prescriptive guidelines on this issue.
Other Issues. Mr. Mikesell provided the Committee two additional handouts but did not discuss them. (See Appendix 10A for a discussion of the DDD's support of the preschool cost study and Appendix 10B for the Wyoming statute governing the creation of a DDD advisory council.) Chair Harvey also passed on a list of concerns to the Department that should be addressed in future meetings: (1) What billing system is the Division currently using to reimburse providers for services? (2) What is the cost of the system to the state? (3) How long has it been since the state has reviewed the reimbursement rates for waiver services? (4) What are the reimbursement rates and explain the divergence in pay for adult providers and children and ABI providers? (5) What process is in place to review the rates in the future? (6) Where can the providers obtain assistance with contract billing?
Tricia Mason, Governor's Planning Council on Developmental Disabilities, addressed the Committee with respect to the upcoming "Statewide Community Forums" (see Appendix 11). Ms. Mason explained the purpose, location, and times of the forums. She also invited participation of Committee members to forums held in their communities. Ms. Mason indicated that the forums are being developed through a consortium of several organizations, and there is an attendance goal of 100 for each event in order to collect input from multiple stakeholders.
Larry Samson, Director of RENEW and Chair-Elect of the Regional Service Providers, testified before the Committee. He expressed gratitude for the opportunity to have input into the new Adult Home and Community Based Service Waiver Rules. He thanked the Committee for the legislation sponsored in the 2005 General Session. He also stated that while the reduction in the waiting list is a phenomenal feat, now is the time to look at the level of funding. He stated that the standard of care needs to be defined and that regional cost differences are not currently accounted for under the waiver. Mr. Samson testified that a cost study is long overdue and inflation does have an impact on funding services. He indicated that adult services are no different than child services. Representative Berger asked if Mr. Samson would put his concerns in writing and disseminate them to the Committee.
After Committee discussion of future meeting dates, Chair Harvey asked that all members submit to LSO any dates in the month of August on which they could not meet. She also added if another meeting is being held that would conflict, to include the location of the scheduled meeting so that staff can identify if multiple meetings could be timed and located together. Chair Harvey indicated the next meeting would be a full-day meeting in the month of August.
There being no further business, Chair Harvey adjourned the meeting at 12:00 p.m.
Respectfully submitted,
Representative Harvey, Chair