The Idaho Department of Health and Welfare (IDHW) has implemented the new “blended” reimbursement rates for adult developmental programs. “Blended” rates were suggested by DD service providers and endorsed by the Department as a way to cut costs for Fiscal Year 2012. The suggestion was embraced by the Legislature in H 260 (see the previous post for information on H260).
Developmental therapy is teaching new skills and behavior patterns to people with developmental disabilities, such as, intellectual disabilities, autism or cerebral palsy. This might be basic self care skills like dressing, grooming, bathing or going to the bathroom, or independence skills like shopping for food, cooking, managing money, using public transportation and house cleaning. Until recently, Developmental Disability Agencies (DDAs) have been paid four different rates for providing the therapy based on whether it was provided on a one to one basis, or in groups and whether it was provided in the community or in a facility. A distinction is no longer made between individuals or groups – there is one rate for serving people in the community ($13.36/hour/person) and one for providing developmental therapy in a center ($12.08/hour/person).
Some skills can be taught to some people very well in groups. Some skills cannot realistically be taught in groups at all. Teaching a person to use the bathroom, bathe or shower, dress, or take care of personal hygiene in a group is patently impossible or inappropriate. Most self-care and independent living skills are best taught one to one.
Whether skills can be taught in a group often depends greatly on the level of learning difficulty experienced by the learner. People who can learn on an abstract level and can generalize a skill to be used in different circumstances may be able to benefit from group instruction. But many people with intellectual disabilities, brain injuries, or severe autism simply cannot do this. People in these circumstances cannot learn “how to use the bus” but with good individual instruction can learn how to take a particular bus route every day to a particular destination. They may not be able to learn “how to use a stove” but can learn how to make a particular set of meals on a particular stove, with markers on their stove and pictures geared to their own adapted stove in their apartment. I could go on to list hundreds of examples, but these illustrate the principle well enough. Indeed, the development of adapted tools and environments and individualized learning strategies in the 1970’s made it possible for hundreds of thousands of people with disabilities to move out of state institutions and to live in the communities with some supports and assistance.
Idaho’s implementation of “blended rates” threatens to virtually eliminate individual therapy by making group therapy much more profitable and making individual therapy a money losing proposition. The rate that Idaho Medicaid has set for home and community based therapy ($13.36/hour) will not cover the cost of a minimally qualified staff person and their payroll taxes, and certainly will not pay for supervision by a professional, training, travel to client’s homes, insurance, etc. In most cases the total cost of providing the service will exceed the new rate. Groups of three, however, will have about the same cost but will be reimbursed at $40.00/hour. This is potentially quite profitable. Medicaid’s hope that agencies will continue to provide individual services at a loss and be satisfied with making it up on a smaller number of group therapy hours has not been fulfilled. Most agencies are virtually eliminating individual therapy and converting almost everyone’s programs to group therapy. Skills that must be taught one to one are not being addressed. Individual learning capabilities are being ignored. Agency employees are being laid off. The system grinds on using state and federal funding, but it will no longer serve its intended purpose which is teaching people with significant disabilities the skills they need to live their lives in the community.
Imagine that you go to a language instructor and ask to learn Spanish. They tell you they can provide really effective instruction but it will cost you $5,000.00. You tell them that you can’t afford that. Well for $4,500.00 they say they can give you an English Spanish Dictionary and a recording of the pronunciation of the 500 most commonly used words. You’re pretty sure that you’re not going to be able to figure out how to speak Spanish from that, but then, hey, you saved $500!
Medicaid will report to the legislature that the change is working because they are spending a small fraction less in state funds. Provider agencies will breathe a sigh of relief because they avoided some cuts that may have put them out of business and now have a way to stay in business and perhaps increase their profits. But in reality, we all lose with this short sighted change because it has virtually eliminated the most effective tool we had for building community survival skills for people with developmental disabilities, individualized instruction. The government will now pay a little less for a service, but will receive far less value for their expenditure. When it becomes apparent that group instruction is not meeting people’s needs, developmental therapy will lose its credibility. Over time we will pay more for the many different problems that will arise from the lack of effective skill building and behavior training. But, as usual, the biggest price will be paid by people who need one to one instruction to get by in the community. For some of them they could lose everything, their opportunity, their independence, their home, their freedom.