Commonwealth of Massachusetts Executive Office of Health and Human Services Chapter 257 of the Acts of 2008 Provider Information & Dialogue Session: Lead Poisoning Prevention, Diagnostics, & Treatment Service Class September 17,

2 OUTLINE Rate Setting Approach General overview Changes since the last Provider Session Rate Structures Individual Casework –Lead Levels 0-14mg/dL –Lead Levels 15+ mg/dL Environmental Cases Health Education Components –Outreach Events & Fairs –Presentations Timeline

3 Billing Units and Establishing a Maximum Obligation Amount Four different categories of activities will be rated: 1.Individual Casework: Monthly rate per case for as long as case is active. There will be two Individual Casework rates based on Blood Lead Level. –Lead Level 0-14mg/dL –Lead Level 15+mg/dL 2.Environmental Cases Monthly rate per environmental case until compliance is reached. 3.Outreach Events & Fairs Billed on a per Outreach Event/Fair basis. 4.Health Education Presentations Billed on a per Presentation basis. Maximum Obligation Amount: In conjunction with providers, DPH will establish a maximum obligation amount based on reasonable benchmark numbers for: Individual Casework: Annual Caseload Outreach Events and Fairs. Health Education Presentations If a provider is either failing to meet or exceeding benchmarks for one of these activities, DPH and the provider may amend the contract to adjust the original benchmarks. Billable Events: The rates are developed to cover the full costs incurred by a reasonably efficient provider. While all activities in which a provider engages are not billable (i.e. phone calls, trainings, etc.), the cost of these activities are built into the rates for the billable activities. Creating more rates for all activities would necessitate more record keeping and billing and result in lower rates.

4 DPH, HCFP and EOHHS had concerns with the survey data collected. Previously, DPH and HCFP collected provider survey data regarding allocation of staff time and costs to different activities. Reported allocation of Program Director and Community Health Worker time was highly variable. It at times yielded counter-intuitive results: for example, there was little to no relationship between the amount of FTEs allocated to health education activities and the number of activities reported. In addition, there is currently substantial variation among programs regarding: The ratio of Program Directors to Community Health workers The proportion of outreach events to presentations in a program DPH and HCFP reached out to providers to try to improve the quality of the data, but the amended information received did not substantially change the original data set.

5 As a result, DPH has indicated assumptions to be used in the rate setting process in place of survey and sometimes contract data DPH Inputs Allocation of Time: Program Director CaseworkOutreach EventsPresentations DPH inputs60%0%40% Range of survey responses0-100%0-55%0-80% Allocation of Time: Community Health Worker DPH inputs70%15% Range of survey responses30-95%2-40%1-30% Program Director FTEs for every 1 CHW FTE DPH inputs.20 Range of contract data0-1+ % Presentations out of all Health Ed/ Outreach Activities DPH inputs70% Range of contract data7-56%

6 Additional data and information provided by DPH DPH also provided HCFP with: FY11 Contract Data Health Education and Outreach numbers by provider, updated to represent a broader definition of presentations and outreach events. Billable Health Education and Outreach Activities include: Presenting information to a group of two or more people Organizing and attending health fairs Setting up table information at a location (Neighborhood event, Doctor’s office, WIC office, Housing court, health clinic) Collaborative meetings

7 All Non-staffing expenses are covered through Individual Casework and Environmental Casework rates. Rather than split out non-staffing expenses across the different activities, DPH and HCFP decided to load the non-staffing costs for health education activities into the casework rates. This: Precludes HCFP from having to rely on varying cost allocation estimates Helps to ensure regular cash flow for providers For providers that do environmental case work as well, HCFP utilized the survey responses to split out the non-staffing expenses that were related to environmental casework. Occupancy expenses were split between the different activities in proportion to the allocation of FTEs Environmental Health Cases ACTIVITY % of Total Cost Category* Staff / Mileage Travel40% Program Supplies & Materials34% Direct Administration Expense17% Occupancy29% *weighted average percentages

8 OUTLINE Rate Setting Approach General overview Changes since the last Provider Session Rate Structures Individual Casework –Lead Levels 0-14mg/dL –Lead Levels 15+ mg/dL Environmental Cases Health Education Components –Outreach Events & Fairs –Presentations Timeline

9 There will be two separate Individual Casework rates based on lead level. Providers report significantly more contacts and visits per case for blood lead levels 15mg/dL and above than for blood lead levels 0-14mg/dL. The proportion of 0-14mg/dL and 15+mg/dL cases varies by provider, so separate rates by lead level are necessary for rates to reflect the variation in service intensity.

10 Individual Casework Rate 1.HCFP calculated the proportion of each provider’s total FTEs that should be for a Program Director (PD) and Community Health Worker (CHW), using the DPH assumption that a program should have.2 Program Director FTE for every 1 Community Health Worker FTE. 2.HCFP allocated 70% of the CHW FTE and 60% of the PD FTE to casework. 3.HCFP split expenses and the resulting PD and CHW FTEs between 0-14mg/dL and 15+mg/dL lead level cases based on the percentage of visits each provider reported conducting. 4.The per case unit cost was calculated for the two lead level categories by taking the FTEs and expenses and dividing them by the number of open cases for each lead level. CHW FTE 1.00 CHW FTE.70 70% Casework 1/3 Visits 2/3 Visits CHW FTE.23 CHW FTE mg/dL Cases 23 Cases 24 ÷ ÷ = FTE per 0-14 Case.01 = FTE per 15+ Case mg/dL 4. *numbers are for illustrative purposes only 1. Total FTEs: PD: 1 CHW 2.3.

11 Individual Casework Rate 4.Lastly, the average total cost of a case is divided by the average length of a case in order to derive a monthly case rate. As another option, DPH could split a casework payment into two payments, one upon assessment of a case and one upon completion. Benefit: There is currently a fair amount of variation in average case length across providers. This option would ensure a provider receives the average total case amount per client even if they tend to complete their cases within a shorter (or longer) time period than average. Con: Providers would not receive payment as frequently under this approach. 123Ave Days Months 5.00 Rounded Months 0–14 mg/dL15+ mg/dL 216Ave Days Months 8.00 Rounded Months

12 Individual Casework Draft Model Budgets One CHW FTE devoting 100% of her time to lead level 0-14 cases would, on average, manage 109 cases in one year. One CHW FTE devoting 100% of her time to lead level 15+ cases would, on average, manage 67 cases in one year. Unit costs are representative of average costs across providers. Since the last proposed rate structures, the administrative allocation percentage increased from 7.18% to 9.18% and the tax and fringe percentage increased from 21.3 to 22.3%.

13 OUTLINE Rate Setting Approach General overview Changes since the last Provider Session Rate Structures Individual Casework –Lead Levels 0-14mg/dL –Lead Levels 15+ mg/dL Environmental Cases Health Education Components –Outreach Events & Fairs –Presentations Timeline

14 Environmental Case Draft Model Budget The Lead Inspection rate is spread over 8 months, the average number of months a case is open. One Lead Inspector FTE would, on average, manage 50 cases in one year. Unit costs Unit costs are representative of average costs across providers.

15 OUTLINE Rate Setting Approach General overview Changes since the last Provider Session Rate Structures Individual Casework –Lead Levels 0-14mg/dL –Lead Levels 15+ mg/dL Environmental Cases Health Education Components –Outreach Events & Fairs –Presentations Timeline

16 Health Education Outreach Event and Presentation Rates 1.HCFP calculated the proportion of each provider’s total FTEs that should be for a Program Director (PD) and Community Health Worker (CHW), using the DPH assumption that a program should have.2 Program Director FTE for every 1 Community Health Worker FTE. 2.HCFP allocated 15% of the CHW FTE to Outreach Events, and 15% of the CHW FTE and 40% of the PD FTE to Presentations. 3.HCFP calculated the proportion of each provider’s total Health Education Events that should be Presentations by taking 70% of the total. 4.The FTE ratios were calculated by dividing the resulting number of CHW and PD FTEs by the resulting number of Presentations and Outreach Events. CHW FTE 1.00 CHW FTE.15 15% Presentations Total Health Education Events 47 Presentations 33 ÷= FTE per Presentation *numbers are for illustrative purposes only 70% Presentations Total FTEs: PD: 1 CHW 3. 4.

17 Health Education Draft Model Budgets One CHW FTE devoting 100% of her time to Outreach Events and Fairs would participate in, on average, 86 events per year. One CHW FTE devoting 100% of her time to presentations would conduct, on average, 200 presentations per year.

18 Tentative Timeline and Next Steps Next Steps: EHS and DPH are working with EIM to determine unit rate invoicing procedures.