iBudget Florida Stakeholders Meeting

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iBudget FloridaStakeholders Meeting
October 22, 2009
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Introduction

• Jim DeBeaugrine
• APD Director
• Betty Kay Clements
• Family Care Council Florida Chairperson

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The Meeting Process

• Facilitator Introduction
• Keep the group focused and on track
• Ensure stakeholder input is heard and recognized

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Introductions

• Workgroup members
• Staff

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Project Background

• APD Challenges to Overcome
• System is complex
• More consumer control possible
• Managing funding is difficult
• Wait list is growing

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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

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• 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 WSCs, choice
  of providers, variety of services, etc.

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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

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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

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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

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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...essentia
  lly takes the place of the step-by-step
  decision-making procedure.

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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.
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Individual Budgets in Florida

• An idea thats 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

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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

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Overall Goals

• Enhance
• Self-direction
• Sustainability
• Equity

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Detailed Objectives

• Empower individuals
• Funding is fair and equitable, yet responsive to
  individual needs
• Protect health and safety

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Detailed Objectives

• Transparent process
• Operate within agency budget
• Meet federal requirements

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• Additional goals and objectives?
• Revisions to stated goals and objectives?

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• Comparison
• CDC
• iBudget Waiver System

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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 arent

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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

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CDC vs. iBudget Florida vs. Flexible Benefit

• Flexible benefit service
• Amendment to all 4 waiversin 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

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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

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Agencys Approach in Developing iBudget

• Researchother states, studies
• Stakeholder and public review and comment
• Expert assistance

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Generic System Elements

• Every system needs
• Way to gather information about peoples needs
• Way to determine funding available for each
  persons needs
• Way to select services that may be paid for with
  the funding
• Different states systems do each differently

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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

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High-Level Program Design

• Current System
• Retrospective, complex
• iBudget System
• Prospective, fair, reliable, and flexible

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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

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iBudget A Self-Directed System

• Assessment Process Consumer Characteristics
  Identification
• Algorithm
• Individual Budgets
• Service Delivery

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Individual Budgets

• People with similar characteristics will have
  similar iBudgets
• Will be process to accommodate those with truly
  unique needs
• Flexible support systems
• Everyone will have an iBudget

• People who are similar will have similar iBudgets
• Flexible support systems
• Universal, not optional

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Individual Budgets

• Distributes appropriations fairly and equitably
• Fits Floridas data and experience
• Model will consider funding patterns prior to
  tier implementation

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• Questions?

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How well do individual budgeting systems
generally work?
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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

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Individual Budget System Outcomes
Wyoming DOORSsince 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
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Individual Budget System Outcomes

• Wyoming DOORSsince 1998 Evaluation by
• Navigant Consulting
• Consumers and families generally satisfied
• Providers generally satisfied

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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

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Assessment Instruments

• What is an assessment instrument?
• A standardized method for collecting
• important information about people

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Assessment Instruments

• What makes a good assessment instrument?
• Reliablethe way it measures will give the same
  result when results should be the same
• Validit measures what its supposed to measure
• Predictive assessment information and other
  factors yield fair and equitable budget amounts

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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

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Assessment Instruments

• What assessment instruments do states use for
  individual budgeting?
• ICAPIndiana, Wyoming
• SISGeorgia, Colorado, Oregon
• Home-grownConnecticut, Minnesota
• States using national instruments often add a
  state-specific supplement

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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

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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 recommendationsdata on product views
• Credit scoresdata on accounts, payment history

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Algorithm

• What makes a good algorithm?
• High r-squarea measure that tells us how well
  a formula fits its data

Higher r²
Lower r²
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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)

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4 Western States Variables
Factors that explain costs and the percent of
variance each explains
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Algorithm

• What makes a good algorithm?
• Fewer variables
• Valid and reliable data
• Useablecan collect data, run it
• Refined over time (ex Wyoming)

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Algorithm

• Models from other states
• Levels
• Determine budget rangestypically 6-7 levels
• Used by states with complex administrative
  systems, problem rates, or data that wont work
• Used in Colorado, Connecticut, Oregon
• Individual budgets
• Potentially thousands or more possible budget
  amounts (depends on variables used)
• Used in Wyoming, Georgia, Minnesota

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Algorithm

• What are other states algorithms like?
• Use different variablesexamples
• 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

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iBudget Algorithm

• In Development
• Expert Consultant Hired
• Preliminary Details Upon Completion of Analysis

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• Questions?

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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

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Service Delivery System

• What makes a good service delivery process?
• Responsive
• Simple
• Supports self-direction

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iBudget Service Delivery System

• Greater flexibility in choosing services
• Example broaden services by combining similar
  services
• Maximize personal control

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Developing a New System

• How do you develop
• a new system?

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Developing a New System

• Four main steps
• Step 1 Prepare
• Step 2 Collect data
• Step 3 Set individual budgets
• Step 4 Implement

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Developing a New System

• Step 1 Prepare
• Set policy goals
• Engage stakeholders
• Choose assessment

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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

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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

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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

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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

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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

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Questions?