Allocation of Resources to Provide Long-Term Services and Supports for Texans with Developmental Disabilities
As previously discussed, Texas has invested heavily in services for people with intellectual and developmental disabilities (I/DD) over the past 30-40 years. Yet, even as the state built a community services system, it has maintained an enduring commitment to ICFs/MR facilities including the state school/center network. With a growing unmet demand for services, changing expectations among people with I/DD and their families, chronic under-funding and other factors, Texas faces difficult policy choices in responding to the needs of its citizens. There is great opportunity to reduce the gaps between current system performance in serving persons with disabilities and performance that meets national benchmarks for capacity and quality.
Texas Current Performance
A gap analysis compares an enterprise’s actual performance to its potential or desired performance — an assessment of the distance between what an enterprise is currently doing and what it could do in the future. The gap analysis begins with defining key expectations for desired system performance. These expectations, or benchmarks, serve as the basis for appraising current performance. A primary and overarching goal in Texas is that everyone supported by the system has a quality service.
TCDD engaged the Health Services Research Institute (HSRI) to conduct an external analysis of how Texas is doing relative to three fundamental, top-level performance benchmarks which were used to gauge the provision of publicly-funded services and supports for people with mental retardation and related conditions. These benchmarks were derived from HSRI’s nationally recognized work in developing quality assurance indicators (i.e., the “Quality Framework” for the Centers for Medicare and Medicaid Services, and the National Core Indicators utilized by over 30 states including Texas).
The complete Gap Analysis, Action Steps, and Implementation Strategies (PDF, 1MB, 89 pages) can be found on TCDD’s website.
A summary of HSRI’s assessment of Texas follows:
People with mental retardation and related conditions have access to and receive necessary publicly-funded services and supports with reasonable promptness.
People with MR/RC in Texas do not have access to services with reasonable promptness. Texas significantly and chronically underfunds its service system, resulting in significant numbers of people who do not receive the supports they need. This is evident in the service utilization rates in Texas that are far below the national average. Insufficient funding also weakens the system’s overall capacity to support the most vulnerable individuals such as those with complex medical needs or behavioral challenges, within the community.
Services and supports are provided in the most integrated setting appropriate to the needs of the individual.
Many people with intellectual and developmental disabilities (I/DD) do not receive services within the least restrictive setting appropriate to their needs. By all measures, Texas relies more heavily on state schools/centers and privately-operated ICFs/MR than most other states. In fact, the discrepancy in Texas’ investment in institutions compared to its investment in community services is extraordinary. Texas ranks seventh highest in the nation in its percentage of people with developmental disabilities living in residential facilities with 16 or more beds. While there have been actions taken to decrease this reliance, stronger actions have been taken to maintain its investment in ICFs/MR options. The pace of relocations from state schools is modest at best. Meanwhile, the state admits children into state schools at a pace twice the national average. And, in FY 2008-2009, the state added 1,690 positions to the state school structure at a cost of approximately $1.04 million.
The system must promote economy and efficiency in the delivery of services and supports.
The state’s service system for people with developmental disabilities is not operated in a manner that promotes efficiency and economy. Texas’ average spending per citizen for MR/RC services was 47 percent below the national average in 2006. Texas continues to devote a greater share of its Medicaid dollars to large congregate care services than is typical nationwide. Furthermore, there presently are no actions underway to reformulate payments to ensure that they are adequate.
The initial examination of information regarding Texas’ current system led to the following observation:
Given the present fiscal effort and how these funds are applied, the state’s system is ill-positioned to address the present and future needs of its citizens with intellectual and developmental disabilities.
In response, fundamental system redesign is necessary for Texas to improve its performance in supporting its citizens with intellectual and developmental disabilities. Absent redesign, system performance will not change appreciably, and will likely deteriorate over time. System redesign is a complex, challenging endeavor, especially in large service delivery systems like the one in Texas.
Moving forward state leaders have several policy options to consider. For instance, the state may:
- Do nothing. Keeping the current investment patterns and service array in place will most likely result in more of the same — i.e., continued inefficient use of resources, a community system that cannot easily meet local service needs, and a growing unmet demand for services.
- Increase funding significantly, but maintain the current system of organizing and delivering services. This approach might help at the margins, but it would tend to perpetuate present inefficiencies, even if most of the new money were to be directed at community systems. Overall, fewer people will be served than might otherwise be the case.
- Keep funding relatively level, but de-emphasize the use of ICFs/MR services in favor of HCBS financing options. The transition itself will require funding, but afterwards the state may drive down its “per participant cost” due to increased reliance on lower cost options. Under this approach, there may be marginal impact on unmet service demand. State leaders, however, must take into account the fact that the present overall fiscal effort is already well under the national average.
- Increase funding significantly and de-emphasize the use of ICFs/MR services in favor of HCBS funding options. This is the most forward-looking option. It would provide a pathway toward increased efficiency within the system while providing needed funds to strengthen the community system and systematically address unmet service demand. Further, it would place the state on a firmer footing in developing a system that can better address present needs while systematically reducing the interest list for services.
The Recommendations to Rebalance the Long-Term Services and Supports System are related to the fourth option. TCDD concurs that Texas can take several steps to rebalance its MR/RC system and make significant progress in serving people in the most integrated setting, expanding system capacity, and strengthening existing community services in the next 10 years.