August 26, 2010
Massachusetts Taxpayers Foundation
333 Washington Street, Suite 853
Boston, MA 02108
President and CEO
75 Arlington Street, 10th Floor
Boston, MA 02116
Dear Messrs. Widmer and Grogan:
We are writing on behalf of The Fernald League, Inc. in response to the July 2010 report, jointly published by your organizations and titled: “The Utility of Trouble: Maximizing the Value of Our Human Service Dollars.”
As you may know, the Fernald League is a family and guardian-supported, nonprofit organization that has been fighting to preserve the Fernald Developmental Center and other Intermediate Care Facilities in Massachusetts for persons with developmental disabilities.
We take exception to the recommendation in your report that all six remaining ICFs in Massachusetts be closed. We believe that with respect to the ICFs, your report is flawed from both a research and policy perspective.
First, there is what we consider an unexamined and unsupported assumption in the report that deinstitutionalization of all Department of Developmental Services clients and the accompanying privatization of their services is beneficial. This assumption discounts evidence that community-based care isn’t right for everyone and that community care in Massachusetts doesn’t meet the stringent standards set forth for ICFs in Title XIX of the Social Security Act.
Your report cites the 1999 Olmstead U.S. Supreme Court decision as mandating community-based care for most individuals with developmental disabilities. But the report fails to acknowledge that the Olmstead decision also states that institutional care remains appropriate for those who wish to remain in institutions and in cases in which their clinicians recommend it.
Secondly, your report’s contention that closing DDS facilities will save money appears to rely solely on numbers provided by the Patrick administration – specifically the “DMR Community Services Expansion and Facilities Restructuring Plan, Revised March 9, 2009.”
The Fernald League asked for backup information for the administration’s cost-saving claims and found that the analysis supporting them was wholly inadequate. For instance, the administration compared the cost of care at the Fernald Center, which primarily houses residents with profound levels of mental retardation and complicated medical issues, with the cost of care for the average resident in the community system. These two populations cannot be treated as if they are identical.
An analysis of 250 studies by the journal Mental Retardation concluded that cost savings are relatively minor when institutional settings are closed and, if there are any at all, they are likely due to staffing costs when comparing state and private caregivers. (Kevin K. Walsh, Theodore A. Kastner, and Regina Gentlesk Green, Mental Retardation, Volume 41, Number 2: 103-122, April 2003.)
In a January 2009 update to the 2003 study, Walsh, the lead author, concluded that the conclusions of the article continued to be valid and stated:
…when certain costs disappear, when individuals are transferred from ICF/MR settings, it is highly likely that these costs will reappear in other state budgets (such as Medicaid). In nearly all instances, this is almost unavoidable. In short, costs don’t just disappear when individuals are moved.
The MTF/BF report should acknowledge that any cost savings in closing institutions would largely come from reduced staffing per client and reduced pay and benefits to caregivers in the community-based system.
The administration’s cost savings projections also failed to include costs of renovating and constructing new facilities for residents transferred from the ICFs. And it did not take into account long-stated proposals to reduce the size of the existing facilities and to allow development of the unused portions of the campuses.
We would make the following additional points about your report:
1. Your report repeats outdated myths about institutions, such as that they are “isolated” and “antiquated.” This disregards the high levels of community interaction and involvement that are characteristic of the staffs and programs at the Fernald Center and the other ICFs. Examples are the Tufts Dental Clinic at Fernald, which primarily treats community-based patients, and the Greene gym and therapeutic pool, which were used by both residents of Fernald and the DDS clients in the community.
Moreover, the use of terms such as “antiquated” in describing the developmental centers also disregards the substantial, court-ordered improvements that have been made to these facilities in Massachusetts since the 1970s. By 1993, Judge Tauro, who oversaw the consent decree that brought about those improvements, described the care provided in the developmental centers as “second to none, anywhere in the world.”
The American Health Care Association has noted, in reference to ICF-level institutions around the country that:
Changes and improvements in ICF/DD support and training services have created one of the most progressive and technically advanced programs anywhere in the world. For residents, quality of life has improved dramatically, as access and choice have become hallmarks of the ICF/DD program. Support and training programs now provide them with increased opportunities to live in more home-like, less restrictive settings and, to the extent possible, to become a more integral part of their communities.
2. Your report claims that levels of abuse and neglect were lower in the community system than in the ICFs, and says this is based on an analysis of Disabled Persons Protection Commission figures from 2007 through 2009.
Your analysis is at odds with U.S. Attorney Michael Sullivan's findings about abuse and neglect, which were part of his 2007 report to U..S. District Court Judge Joseph Tauro. Attorney Sullivan’s findings were based on DCCP figures for ICFs from 1996 through 2007, and for vendor homes from 2002 through 2007. Sullivan's report stated that there were "much higher" levels of physical abuse in the vendor homes than in the ICFs and higher levels of sexual abuse in the vendor homes than in the ICFs. He reported there was little to no sexual abuse reported in the ICFs.
Your report, moreover, acknowledges that your analyses "did not adjust for differences in the caseload of clients served or the reporting practices in different settings that may contribute to different rates."
We think that caveat in your report is an important one. We would submit, for instance, that abuse and neglect are more likely to be reported in the ICFs than in the community-based system because of the more concentrated presence of doctors and clinical staff in the ICFs, who are knowledgeable about signs of abuse.
3. Your report seems intellectually inconsistent in arguing, on the one hand, that consolidating area offices in the Executive Office of Health and Human Services would achieve economies of scale and convenience for clients, and, on the other, that all DDS clients should live in widely dispersed group homes.
Why shouldn’t the convenience and economies-of-scale arguments apply in the case of the developmental centers as well? In fact, they do. The centralized delivery of services in institutions such as Fernald offers savings in transportation, clinical, dental and other costs, and offers convenience to the residents, who receive their clinical, medical, and program services in one location.
In closing, we are dismayed that your report goes even further than the Patrick administration in urging the closure of all remaining ICFs in Massachusetts. The Massachusetts Taxpayers Foundation and the Boston Foundation are taking a radical position in t
his regard, which would have devastating consequences for persons with the most profound levels of mental retardation, medical issues, and behavioral issues.
Even the Department of Developmental Services has acknowledged that ICF-level care is not only needed in Massachusetts, but may in fact be less expensive on an individual basis for certain hard-to-serve clients than community-based care. (See the Report of the DMR Facility Planning Working Group, May 2002, Appendix 7).
Alfred Bacotti, a former Director of the Glavin Regional Center, has noted that the Glavin Center, now slated for closure, has served as a backup to individuals with developmental disabilities who experience “extreme difficulty” in community settings. He also pointed out that services provided to individuals at Glavin, such as non-time limited psychiatric stays and dental, are not currently available in the community system.
There is no doubt that our human services tax dollars could be spent more wisely. We commend the Massachusetts Taxpayers Foundation and the Boston Foundation for taking on this issue and producing a report that opens these issues to public debate. However, we do not believe that the major finding and recommendation in this report dealing with the future of the DDS system advances this debate in a meaningful way.
The Fernald League, Inc.