Where is the Pea?

(game in which three nutshells are moved about on a table & you must guess the one with a pea underneath)

More than 4 years after its implementation the Disability Waiver Rate System continues to confuse clients and their families, puzzle case managers and county clerks, and delay payments to providers due to untimely and incorrect service agreements. So why did the Minnesota Disability Services Division (DSD) decide to make things even more difficult by fracturing Supported Employment Services (SES) into three distinct services called employment exploration (EES), employment development (EDS), and employment support (ESS)?

Some at DSD have stated that it was to track and report on the wages of those with Intellectual or Developmental Disabilities (I/DD) paid directly by the business. A few mention it was needed to meet the reporting requirements of either the Statewide Transition Plan, Olmstead Plan, or both. Others at DSD explain it was to better define distinct actions within the three services and calculate a sufficient rate. Finally, an official DSD presentation suggests it came out of the 28 employment and day services stakeholder workgroup meetings it has hosted since 4/14/15 and the 20 town-hall community stakeholder meetings conducted throughout the state in 2016.

Having read most public documents (i.e., Center for Medicare and Medicaid Services [CMS], Department of Justice [DOJ], DSD, & Olmstead Office) related to the state’s Medicaid (MA) “reform initiatives,” in my opinion all of this is a bunch of hooey and the real reason is DSD wants to diminish the purpose of Day Training & Habilitation (DT&H) programs with an end-game to close these center-based programs. Don’t believe me? Consider the following:

  1. I have not found any CMS, DOJ, or court mandate to collect and report the hours worked and wages earned by people with I/DD. In fact, DT&H providers were required to report this annually to DSD until they simply decided to stop collecting that information (I believe it is still legislatively required). Still, if that would be useful, those with I/DD paid by the business have W-2 forms issued by the employer that could be used by case managers to report wages earned. That said, since the three new employment waivers do not require hours worked or wages earned to be reported this cannot be the reason for the change.
  2. The Statewide Transition Plan is the DSD document to ensure compliance with the Home and Community Based Services (HCBS) guidance from CMS that requires waiver recipients to: (i) have enough information to make informed choices about the type of service they receive; (ii) be treated with respect and in a person-centered way so they can make decisions about how, when, and where to get services; and (iii) have the opportunity to be involved in their community – including living and working in integrated settings and coming and going where and when they want. SES utilization data from MMIS could have accomplished this as easily as the new employment waivers.
  3. The Olmstead Plan (March 2018, page 25) has the following three goals: (i) by 9/30/19 the number of new individuals receiving Vocational Rehabilitation Services (VRS) and State Services for the Blind (SSB) who are in competitive, integrated employment will increase by 14,820; (ii) by 6/30/20, of the 50,157 people receiving services from certain Medicaid funded programs, there will be an increase of 5,000 over baseline to 11,137 in competitive integrated employment; and (iii) by 6/30/2020, the number of students with developmental cognitive disabilities, ages 19-21 that enter into competitive integrated employment will be 763. VRS has, or should have, the capability to report on goal one and the Department of Education has, or should have, the capability to report on goal three. This leaves only goal two, which could have been measured by the increase in SES utilization as reported by MMIS.
  4. Admittedly the employment waivers are better defined than SES. Still, those definitions could have been used for SES and the slight difference in the EES, EDS, and ESS rates is simply not worth the added complexity. As to the sufficiency of the new rates, while better than SES, it appears most clients will lose funding in the transition from DT&H to the employment waivers. Finally, SES did not have any time limits that have been added to EES and EDS and, in my view, are contrary to the basic principles of the Olmstead Plan.
  5. DT&H programs have been finding minimum wage jobs for clients in their programs for decades and DSD has just recently “gotten into the game” and knows next to nothing about what it takes to make this work for someone with an I/DD. With regard to their 48 stakeholder meetings, DSD did not ensure that a representative sample of recipients participated and, in my view, only hears input that aligns with their predetermined course of action.

So, as the three nutshells are being deftly moved about the table, what has happened since the 7/1/18 implementation of the three new employment waivers?

  1. EES, EDS, & ESS rates are “new” and therefore not “banded” and rates that were already insufficient were cut by 7% on 7/1/18. This negatively impacted providers earlier than intended and in doing so circumvented the Legislature’s intent to stabilize the service system. Preposterous you say? One provider and one program have already closed their doors since 7/1/18 and thereby narrowed choices available to recipients with I/DD.
  2. Whereas providers previously tracked and billed for just SES, we now must track and bill for three different services that could occur on the same day along with DT&H services. The time to do this for 120 clients at Merrick is not understood or funded by DSD, is simply overwhelming case managers, and is very hard to explain to clients and their families.
  3. DSD had to also add a new 1-way waiver transportation rate for EES, EDS, and ESS clients that is not consistent across the state (required by CMS) or well defined. This has added more stress to the system as lead agencies and providers attempt to find an agreeable rate when it should be set by DSD. Some feel the transportation study being conducted by Navigant will resolve this issue and many in that DSD workgroup seem skeptical.
  4. For all of these reasons, incorrect service agreements have resulted in our accounts receivable going up by $100K since 7/1/18 and other providers are having to draw on their Lines of Credit and pay interest for carrying the state’s debt. It is unreasonable for DSD to expect non-profit providers to pay this unnecessary added expense when most of our rates are going down.
  5. And the kicker? None of this makes a “lick of difference” to clients on work crews or interested in competitive integrated work. Nor does it help DSD comply with any federal, court, or state mandate. DSD will argue it does and it is all self-talk to reinforce their tactics that go against common sense actions and client choice.

So where is the pea? It is not even on the table! It’s that thing that makes you feel uncomfortable, for reasons that may not be evident, when you lay your hands on the DSD plan to redesign DT&H services and revise the need determination process. It is that “bump” in-between sentences revealing their intention of “starving” center-based programs out of existence. And though they publicly state they are not trying to close center-based programs, why is DSD distracting our attention while they move in that direction? Because they only intend to fund clients that can earn a minimum wage with minimum support and all others will get very little service with infrequent “van therapy” by the residential provider to meet the minimum requirements for community inclusion. In short, don’t work – don’t count.

In October 2018, Governor Dayton issued a proclamation that the State was “committed to providing Minnesotans with disabilities a continuum of work options…”. Moreover, the year two results from the Career Counseling Information & Referral process, completed by a pro-employment first agency, reports that 85.7% of those making a special minimum wage in centered-based programs are not interested in competitive integrated employment. It seems reasonable to think that leadership at DSD would be sensitive enough to feel the pea and make it their goal to preserve as many service options as possible to best meet the choices of adults with I/DD and comply with the Olmstead Plan. They don’t.