Transcript iBudget Florida Stakeholders’ Meeting

iBudget Florida
Stakeholders’ Meeting
October 22, 2009
1
Introduction
Jim DeBeaugrine
APD Director
Betty Kay Clements
Family Care Council Florida Chairperson
2
The Meeting Process
Facilitator Introduction
– Keep the group focused and on track
– Ensure stakeholder input is heard and
recognized
3
Introductions
• Workgroup members
• Staff
4
Project Background
APD Challenges to Overcome
– System is complex
– More consumer control possible
– Managing funding is difficult
– Wait list is growing
5
Why are individual budgets
worth considering?
• Several states use similar models
• Individualized budgets can help with agency
challenges
• Florida is well positioned to succeed
• Vulnerabilities no greater than current system
• Other options raise concerns
• Legislature told us to develop a plan
6
Why are Individual Budgets
Worth Considering?
• Emerging best practice--several states use
similar models
– Examples: Georgia, Wyoming, Minnesota,
Connecticut, Louisiana
• Florida is well positioned to succeed
– Has key building blocks in place: statewide
rates, fee-for-service, independent WSC’s,
choice of providers, variety of services, etc.
7
Why are Individual Budgets
Worth Considering?
• Can help with agency challenges and
achieve agency goals
– Can increase self-direction, sustainability,
equity
• Vulnerabilities no greater than current
system
– Agency & individual budget cuts can and do
happen now
8
Why are Individual Budgets
Worth Considering?
• Other options raise concerns
– Managed care
– Continued deficits, growing waitlist,
awkward legislative cost-control
measures
• Legislature told us to develop a plan
9
Current
System
Potential
iBudget System
Service
Needs
Review
Service
Needs
Review
Complete
Support Plan
Determine Total
Funding Amount
Complete
Support Plan
Complete PSA
Determine Total
Funding Amount
YES
Streamlined
Approval
Services to
Support
Goals
Needs
Approval?
NO
Services to
Support
Goals
10
What is an individual budget?
• A formula
– Computer calculates individuals’ budgets
– Uses mathematical formula or algorithm
– Uses consumer characteristics and
assessment results
– Funding is determined before services are
decided upon
• A process
– For selecting services
11
What is an individual budget?
Chas Mosley, NASDDDS
“In many states, the . . . budget is built
through a developmental process in which
people receiving support and their planning
teams actively participate in a series of
structured decisions. ... The statistical
analysis...essentially takes the place of the
step-by-step decision-making procedure.”
12
Example of an individual budget
5,000 (Living setting)
+ 100 (age)
+2,300 (subscore 1)
+1,500 (subscore 2)
= Total
$15,000 (coded 3)
+ 3,000 (30 yrs old)
+ 4,600 (score of 2)
+ 4,500 (score of 3)
= $27,100
***This is for illustrative purposes only
and is not a proposed formula.
13
Individual Budgets in Florida
• An idea that’s been around a while:
– District 13 Model:
• 43 levels based on primary challenge, living
situation, and level of need
– 2002-03 Redesign Efforts:
• Envisioned valid & reliable assessment
(ICG), cost prediction model, and flexible
services system
14
Project Background
Legislative Direction: Plan by February 2010
– Fair and equitable distribution of resources
based on assessment process
– Client choice of services and providers
– Formulas to predict resource needs
– Recommended roles for providers and support
coordinators during the assessment process
15
Overall Goals
Enhance:
– Self-direction
– Sustainability
– Equity
16
Detailed Objectives
1. Empower individuals
2. Funding is fair and equitable, yet
responsive to individual needs
3. Protect health and safety
17
Detailed Objectives
4. Transparent process
5. Operate within agency budget
6. Meet federal requirements
18
•
Additional goals and objectives?
•
Revisions to stated goals and
objectives?
19
iBudget
Calculation
Comparison
• CDC+
• iBudget Waiver System
Service System
Selection
CDC+ (Limited
Enrollment)
iBudget Waiver
System
20
CDC+ vs. iBudget Florida
vs. Flexible Benefit
• All are designed to give more flexibility to
families, but in different ways
• They are in different stages of implementation
• Some are optional, some aren’t
21
CDC+ vs. iBudget Florida
vs. Flexible Benefit
CDC+
– Existing program being expanded
– May hire own workers
– Use fiscal employer agent service to pay
workers and providers
– Must opt into
22
CDC+ vs. iBudget Florida
vs. Flexible Benefit
Flexible benefit service
– Amendment to all 4 waivers—in process
– Must opt into
– Choose from Medicaid enrolled providers
– No fiscal employer agent service
– More flexibility with meaningful day services
– May be encompassed in iBudget FL
23
CDC+ vs. iBudget Florida
vs. Flexible Benefit
iBudget Florida
– Plan in development – seeking Legislative
direction
– Not optional
– All consumers would have funding determined
– All consumers would have new service
flexibility, except for CDC+ consumers (they
keep their current broad flexibility)
– Choose from Medicaid enrolled providers
24
Agency’s Approach in
Developing iBudget
•
Research—other states, studies
•
Stakeholder and public review
and comment
•
Expert assistance
25
Generic System Elements
• Every system needs:
– Way to gather information about peoples’
needs
– Way to determine funding available for each
person’s needs
– Way to select services that may be paid for with
the funding
• Different states & systems do each differently
26
Current System
• Determine needs through WSC review,
assessment instrument
• Determine funding through WSC
recommendation, prior service
authorization (PSA) process, law/rule
mandates
• Determine services through choice limited
by handbook, PSA
27
High-Level Program Design
•
Current System
– Retrospective, complex
•
iBudget System
– Prospective, fair, reliable, and flexible
28
Key Differences
Current System
– Services decided first
– Complex system:
•
•
•
•
WSC writes plan
Area & PSA review
Rebasing affects
Tiers affect
– Change in services
often requires new
PSA review
iBudget Florida
– Funding decided first
– Simpler, flexible
system:
• Budget up to individual
limit
• Limited service review
• Process for
accommodating
individuals with
extraordinary needs
29
iBudget – A Self-Directed System
•
Assessment Process & Consumer
Characteristics Identification
•
Algorithm
•
Individual Budgets
•
Service Delivery
30
iBudget –
Determining
Individual Budgets
$
iBudget 1
$
iBudget 2
QSI
Assessments
$
Individual
Characteristics
iBudget 3
iBudget
Algorithm
$
iBudget 4
Other
Variables
$
(* 29,000 ~ Waiver Participants)
iBudget 29,000*
31
Individual Budgets
•
People with similar characteristics will
have
similarwho
iBudgets
• People
are similar will have
similar
iBudgets
– Will
be process
to accommodate those with truly
needssupport systems
• unique
Flexible
• Universal,
not
optional
• Flexible
support
systems
•
Everyone will have an iBudget
32
Individual Budgets
•
Distributes appropriations fairly and
equitably
– Fits Florida’s data and experience
– Model will consider funding patterns prior to
tier implementation
33
iBudget – Service Delivery System
Service 1
$
iBudget
Consumer
Support Plan
and Cost Plan
Development
Service 2
Service 3
Service 4
34
•
Questions?
35
How well do individual
budgeting systems
generally work?
36
Individual Budget
System Outcomes
• Human Services Research Institute staff
– States can implement in a budget-neutral
manner and have been able to constrain
costs
• Florida District 13 Pilot
– Increased predictability of costs, accepted by
families
• Former Wyoming Staff Member:
– “Families love it”
37
Individual Budget
System Outcomes
Wyoming DOORS—since 1998: Evaluation by
Navigant Consulting
• DOORS “...continues to perform as it was originally
•
intended: distributing waiver funds equitably across
the population of individuals enrolled in the HCBS
waivers while matching consumer needs with
available supports.”
Increases in costs are due to increased enrollment
and exceptional/changed need funding process
38
Individual Budget
System Outcomes
Wyoming DOORS—since 1998: Evaluation by
Navigant Consulting
• Consumers and families generally satisfied
•
Providers generally satisfied
39
Individual Budget System
Outcomes
Implementation Recommendations
– Evaluate individual impacts
•
•
Can phase in new amounts
Have special process for exceptional needs
– “New system issues”
•
Can phase in geographically or other method
40
Assessment Instruments
What is an assessment instrument?
A standardized method for collecting
important information about people
41
Assessment Instruments
What makes a good assessment instrument?
• Reliable—the way it measures will give the
same result when results should be the same
• Valid—it measures what it’s supposed to
measure
• Predictive – assessment information and other
factors yield fair and equitable budget amounts
42
Assessment Instruments
What makes a good assessment instrument?
• Also need to think about:
•What consumers assessment is intended for
•Time it takes to administer
•Who can administer
•Training required for administration
•Nature of assessment
•Cost of assessment
43
Assessment Instruments
• What assessment instruments do
states use for individual budgeting?
– ICAP—Indiana, Wyoming
– SIS—Georgia, Colorado, Oregon
– “Home-grown”—Connecticut, Minnesota
• States using national instruments
often add a state-specific supplement
44
QSI in Use Now…
•
Validity and reliability studies indicate the
QSI is comparable to similar instruments
•
Can revise to meet state needs
•
About 50,000 assessments completed
– Large sample size is great for algorithm
development
•
Administered by trained and certified APD
staff
45
Algorithm
• What is an algorithm?
– Mathematical formula that considers data
(consumer characteristics) and determines a
budget amount
– Captures patterns of spending for similar
consumers from previous years
– Used in many other contexts:
• Amazon.com recommendations—data
on product views
• Credit scores—data on accounts,
payment history
46
Algorithm
What makes a good algorithm?
• High “r-square”—a measure that tells us how well a
formula fits its data
Higher r²
Lower r²
0. 35
1. 2
0. 3
1
0. 25
0. 8
0. 2
Ser i es1
0. 6
Ser i es1
0. 15
0. 4
0. 1
0. 05
0. 2
0
0
0
5
10
15
20
25
30
35
40
45
0
5
10
15
20
25
30
35
47
Algorithm
•
•
1.0 is perfect fit to data; but unattainable
due to unique circumstances
Wide range of “goodness of fit”
•
•
•
•
•
Louisiana: .46
Georgia: .75
Colorado: .26 & .51 (two waivers)
Oregon: .45
Wyoming: about .80 (started at .50)
48
4 Western States’ Variables
Factors that
explain
costs and
the percent
of variance
each
explains
Unknown
30%
ICAP
Summary
Score
29%
Geographic
Measures
4%
Living Setting
32%
ICAP other
5%
49
Algorithm
What makes a good algorithm?
• Fewer variables
• Valid and reliable data
• Useable—can collect data, run it
• Refined over time (ex: Wyoming)
50
Algorithm
•
Models from other states
– Levels
• Determine budget ranges—typically 6-7 levels
• Used by states with complex administrative
systems, problem rates, or data that won’t work
• Used in Colorado, Connecticut, Oregon
– Individual budgets
• Potentially thousands or more possible budget
amounts (depends on variables used)
• Used in Wyoming, Georgia, Minnesota
51
Algorithm
What are other states’ algorithms like?
• Use different variables—examples:
–
–
–
–
–
–
–
–
–
–
Subscales or sections from assessments
Overall scores from assessments
Individual questions from assessments
Diagnosis
Age
Living situation
Services received
Chronic conditions
Mental health status
Community safety risk
• States may use just a subset of these
52
iBudget Algorithm
•
In Development
•
Expert Consultant Hired
•
Preliminary Details Upon Completion
of Analysis
53
•
Questions?
54
Service Delivery Process
• What is a service delivery process?
– The “roadmap” that is followed from budget
determination to service delivery and beyond
– Includes planning, service identification,
provider selection, monitoring, and more
55
Service Delivery System
• What makes a good service delivery
process?
– Responsive
– Simple
– Supports self-direction
56
iBudget Service Delivery System
• Greater flexibility in choosing services
– Example: broaden services by combining
similar services
• Maximize personal control
57
Developing a New System
How do you develop
a new system?
58
Developing a New System
Four main steps:
• Step 1: Prepare
• Step 2: Collect data
• Step 3: Set individual budgets
• Step 4: Implement
59
Developing a New System
Step 1: Prepare
• Set policy goals
• Engage stakeholders
• Choose assessment
60
Developing a New System
Step 2: Collect data
• Collect information on individuals and
the system
– Full population is best
– Ensure it is accurate
• Compile the collected information
61
Developing a New System
– Step 3: Set individual budgets
• Set individual budgets
– Put data into the computer
– Use regression analysis to create
formula that is best fit model
• Review findings in relation to policy goals
– Health and safety
– Equity
62
Developing a New System
– Step 4: Implement
• Consider potential implementation issues
• Plan for implementation
– Modify rules
– Build awareness
– Provide training
– Modify operating procedures, forms, IT
systems
• Implement new practices
63
Proposed Plan
Development Timeframe
• October: Gather stakeholder ideas
• November and December: Statistical
analysis, policy option development
• January: Stakeholders review draft plan,
second round of public meetings
• February: Plan to Legislature
64
Suggested High-Level
Implementation Plan
• Pending feedback from Legislature:
–
Draft to Legislature: February 1, 2010
–
CMS approval sought as soon as possible
–
Phase-in begins Summer/Fall 2010
–
QSI improvements/algorithm refinement:
Through Spring/Summer 2011
–
Wider phase in begins Summer/Fall 2011
65
Questions?
66