Protecting Vulnerable Pennsylvanians by

Preserving Services for People with Mental Illness, Substance Use Disorder,

Intellectual Disabilities and Autism

Funding for Community-based Behavioral Health and Intellectual Disability Services Has Already Been Cut,

and Cut, and Cut.

Payment rates for these services have not kept pace with (a) inflation (CPI), (b) the Home Health Market Basket Index, or (c) the State General Fund over the past two decades. See Chart 1 attached.

Over the past twenty years, payment rates for these services

have been cut 40% compared to the cost of providing these services.

Over the past eight years, the Governor proposed cost-of-

living adjustments to these payment rates in only three of the last eight years. In both FY 2005 and FY 2009, the Legislature added funding for payment rate increases at less than inflation. See Chart 2 attached.

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90-91 91-92 92-93 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-11

State General Fund 0.00% 12.89% 14.20% 21.10% 26.19% 30.58% 32.57% 39.03% 45.70% 55.21% 60.85% 67.21% 66.76% 72.78% 85.41% 97.25% 111.95 119.02 128.03 124.38 133.71

HHMBI 0.00% 4.75% 7.82% 12.12% 15.34% 18.40% 21.47% 24.85% 28.68% 32.52% 37.42% 43.10% 48.01% 52.61% 57.67% 62.42% 67.48% 73.31% 79.14% 82.52% 87.12%

CPI-U (Seasonally Adj) 0.00% 3.01% 6.10% 8.75% 12.06% 15.22% 17.79% 19.71% 22.06% 26.62% 30.66% 32.06% 34.63% 38.90% 42.43% 48.46% 52.35% 59.76% 57.76% 59.51% 63.61%

BH/ID/A Reimbursement 0.00% 3.00% 5.06% 7.16% 9.30% 9.30% 9.30% 11.49% 13.72% 15.99% 18.31% 20.68% 20.68% 20.68% 23.09% 25.56% 28.07% 31.91% 33.23% 33.23% 33.23%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

140.00%

160.00%Cu

mul

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Cha

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Over the Past 20 Years, BH/ID/A Reimbursement Lags Far Behind Increases in the State General Fund and in Inflation

HHMBI

CPI-U (Seasonally

Adj)

BH/ID/A Reimbursement

State General

Fund

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BH/ID COLAs by Fiscal Year Actual Compared to HHMBI

FiscalYear93-94 0.00% 0.00% 0.00%

94-95 2.00% 2.83% -0.83%

95-96 0.00% 2.75% -3.66%

96-97 0.00% 2.59% -6.39%

97-98 2.00% 3.15% -7.77%

98-99 2.00% 2.88% -8.91%

99-00 2.00% 3.73% -11.08%

00-01 2.00% 4.25% -13.98%

01-02 2.00% 3.45% -16.06%

02-03 0.00% 3.18% -20.15%

03-04 0.00% 3.31% -24.55%

04-05 2.00% 2.99% -26.40%

05-06 2.00% 3.45% -28.97%

06-07 2.00% 3.40% -31.60%

07-08 3.00% 3.30% -33.01%

08-09 1.00% 3.00% -37.69%

09-10 0.00% 2.00% -39.67%

10-11 0.00% 2.10% -43.12%

MH/MR COLA HHMBI** Difference

**Home Health Market Basket Index.Source: Global Insight.

Payment Rates for Community-based Behavioral Health and Intellectual Disability Services Have Lagged Behind

Other Major Medicaid Service Providers Over the Past Twenty Years.

Annual payment rate increases for Medicaid MCO’s and Nursing Homes far exceeded payment rate increases for hospitals, which exceeded the payment rate increases for home and community-based behavioral health and intellectual disability services. See Chart 3 attached.

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FY1994

FY1995

FY1996

FY1997

FY1998

FY1999

FY2000

FY2001

FY2002

FY2003

FY2004

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010

FY2011

MCOs 0.00% 7.40% 10.84% 7.29% 9.44% 13.81% 23.21% 33.02% 46.96% 62.44% 69.75% 81.63% 93.25% 100.98 107.01 119.31 130.28 144.09Nursing Homes 0.00% 10.20% 20.43% 29.04% 37.18% 45.36% 52.77% 64.96% 76.37% 88.79% 97.00% 108.04 113.86 122.42 126.86 126.86 129.13 133.26State General Fund

(State $ Only) 0.00% 4.21% 7.45% 9.08% 14.41% 19.90% 27.73% 32.37% 37.61% 37.24% 42.19% 52.58% 62.33% 74.43% 80.25% 87.75% 66.81% 74.09%

Hospitals 0.00% 3.70% -1.49% 0.49% 3.20% 5.26% 8.21% 11.46% 15.91% 20.70% 21.91% 24.96% 27.46% 32.55% 35.20% 35.20% 35.20% 35.20%BH/ID/A

Reimbursement 0.00% 2.00% 2.00% 2.00% 4.04% 6.12% 8.24% 10.41% 12.62% 12.62% 12.62% 14.87% 17.17% 19.51% 23.09% 24.33% 24.33% 24.33%

-5.00%

10.00%

25.00%

40.00%

55.00%

70.00%

85.00%

100.00%

115.00%

130.00%

145.00%

160.00%C

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BH/ID/A Reimbursement Lags Well Behind the Increases in Medicaid Payments Received by Other Major Medicaid

Providers in Pennsylvania

Source: Governor's Executive Budget

MCOs

Nursing Homes

State General Fund

Hospitals

BH/ID/A Reimbursement

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The Cost of Community-based Behavioral Health and

Intellectual Disability Services is Less than Half the Cost of State Institutions.

The average cost per resident in state MR Centers is

$256,622 compared to the average cost of residential and day program services in the community for people with intellectual disabilities of $112,000, or 44% of the cost of the mandatory Medicaid entitlement alternative. See Chart 4 attached.

The average cost per patient in State Mental Hospitals is $195,891 compared to the average cost of residential and day treatment services in the community for people with mental illness of $60,850, or 31% of the cost of care in state institutions. See Chart 4 attached.

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$256,622

$112,000

$195,891

$60,850

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

State MR Centers Community ID Programs State Mental Hospitals Community BH Programs

Ave

rage

Cos

t per

Per

son

FY 11 Average Cost per Person State Insitutions vs. Community Programs

The Cost of Direct Support Personnel is Twice as High in State Institutions as in Community Programs.

Based on a Legislative Budget and Finance Committee report1, the average hourly wage for direct support personnel in community-based programs ($8.84), is less than half the wages paid ($17.78) in state institutions and the difference continues to widen.

The Average annual wage of a direct support professional in a community setting ($18,390) is only slightly above the federal poverty guidelines for a family of three.2

1 LBFC Report on Salary Levels and Their Impact on Quality of Care for Client Contact Workers in Community Based MH/MR

Prorgams http://lbfc.legis.state.pa.us/reports/1999/204.PDF

2 American Network of Community Options and Resources (ANCOR) 2008 Direct Support Professional Wage Study

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Opportunities for Cost-Shifting to Other Payers is Almost

Non-Existent.

The state (with matching federal funds) is the single payer for

community-based behavioral health and intellectual disability services.

There is almost no private pay (less than 1%) for these services.

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The Almost Exclusively Non-Profit Providers of these Services are Financially Fragile.

For 45 years, DPW payment policy and county MH/MR

agency practice severely limited retained revenue.

County contracts, DPW fiscal regulation, and ODP Instructions to Cost Reporting carefully limit allowable costs.

Cash advances from counties, and now gross adjustments from DPW, continue to be necessary to ensure adequate cash flow for many of these community-based providers.

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Cuts in these Services will Increase Costs Elsewhere in

State and County Government.

County jails and state prisons are among the default

treatment option for people with autism and untreated behavioral health needs.

Cuts that lead to program closures for people with intellectual disabilities will result in a re-institutionalization policy contrary to the Americans with Disabilities Act at greater expense to the state budget.

The lack of adequate Waiting List funding for people with intellectual disabilities is resulting in Section 406 commitments to state MR institutions by county common pleas courts, at a cost of $256,622 per person per year, which will only accelerate if further cuts are made.

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Traditional Cost Cutting Measures (Serving Fewer People or

Providing Fewer Services) are Not Available in the Community ID Waivers.

Existing waiver participants cannot be terminated from ID

waivers, according to federal law, and there is almost no turnover of the people enrolled in these waivers.

The amount and kinds of services provided to ID waiver participants cannot be cut back, according to federal rules.

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Medicaid Waiver Services for People with Autism Must Be Preserved

Two Medicaid waivers generate federal matching funds for services for 500 adults with autism spectrum disorders.

The preservation of these services will help to reduce costly and inappropriate “care” for people with autism, including county jails and state prisons.

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