By Gina Macris
When she became director of Rhode Island’s developmental disability agency in February, 2015, Maria Montanaro inherited a budget with no relation to actual costs that was destined to run a deficit.
She had to work with a state-run system of group homes resistant to change, which she said exists to preserve jobs and not to serve clients.
And she had virtually no high-level staff to form the leadership team necessary to move forward on compliance with the 2014 federal consent decree that requires Rhode Island to transform its services for adults with disabilities from segregated programs to integrated, community-based supports.
A little more than a year into the job, as she was trying to reduce costs to hit a budget target that seemed plucked out of thin air, Montanaro realized that working in state government was not for her.
She said Governor Gina Raimondo and the Secretary of Health and Human Services, Elizabeth Roberts, have been very supportive. After favorable state revenue estimates in May, Raimondo added to her budget request for developmental disabilities, and the General Assembly gave her most of what she wanted.
Nevertheless, the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) needed everything the governor asked for - a total of $16.9 million in new Medicaid funding, Montanaro said.
In March, Raimondo had asked her to stay on until the budget process was complete, Montanaro said, and she agreed.
In the end, the political aspect of running BHDDH proved to be ‘very draining,” said Montanaro. Her last day at BHDDH is June 24.
“It takes an enormous amount of effort to move the levers” of state government, she said in a recent interview. Formerly CEO of Magellan Behavioral Healthcare in Iowa and the Thundermist Health Center in Rhode Island, Montanaro had never worked in state government before she came to BHDDH.
In public statements in recent weeks, Montanaro has helped start a new conversation about splitting up BHDDH – a change that could not come without legislation enacted by the General Assembly.
Accustomed to dealing with budgets as professional challenges, Montanaro said she found that trying to get funding in the right places is also a political issue in state government. That was “very difficult for me,” she said.
It was “enormously frustrating,” she said, to inherit a system of fragmented services and balance sheets always running millions of dollars in the red. (The deficit has averaged about $4.6 or $4.7 million for the past eight years.)
She offered a frank analysis of what’s wrong at BHDDH, and the reasons the Division of Developmental Disabilities should be a separate entity, with its own commissioner, working hand in hand with the state’s Medicaid administrator.
“Politics aside, there is a responsibility to adequately fund the system,” Montanaro said.
Actually, there are two systems of care in Rhode Island for adults with developmental disabilities, and Montanaro indicated that is one of the problems.
One division of BHDDH operates a network of 25 group homes serving roughly 150 adults with a staff of less than 400 employees. The division is known as Rhode Island Community Living and Supports (RICLAS).
BHDDH also contracts with about two dozen private agencies which, in turn, hire some 4000 workers to serve roughly 3,600 clients day and night, including some 1,120 adults with intellectual challenges who live in about 250 group homes.
Montanaro said the one good thing about the state-run homes is that employees are paid adequately. Their pay ranges from $15 to $25 an hour. Direct support workers in the private sector make minimum wage or a little higher - an average of about $11.50 an hour. Burnout is high, and turnover runs an average of about 35 percent, according to testimony presented to the House Finance Committee last month.
“RICLAS as a provider system needs to make changes, and it’s very hard to enact change with a unionized workforce with very rigid views on change,” she said. “We have a lot of limitations in negotiating those changes. Do we need a state-run residential system?” Montanaro says she thinks not.
“Why not do that in the private sector; use contracts and incentives in the private sector to make sure we get people what they need,” Montanaro said.
“We should not be running a system to employ people. We should be running a system to serve clients,” Montanaro said.
Services for adults with developmental disabilities are all funded by Medicaid, Montanaro said, and the future costs can be projected fairly accurately by looking at the state’s costs for the past three years.
Montanaro contends that the social support services funded by Medicaid through the Division of Disabilities probably avoid medical costs in the long run. The social supports, like job coaching and other services, “allow them to live their best life, doing meaningful work and having a meaningful personal life,” Montanaro said. People who are more active and engaged in their communities are not as sick, using fewer medical services, Montanaro said.
“That is why I am arguing to change the structure,” she said, She envisioned a separate unit run by a commissioner of developmental disabilities – someone like Charles Moseley, a developmental disability career professional who formerly served as commissioner in Vermont.
Moseley is now the federal court monitor for compliance with the 2014 consent decree which requires Rhode Island to transform its segregated system into an integrated one over a 10-year period in accordance with the 1999 Olmstead decision of the U.S. Supreme Court. That decision clarified the integration mandate of the Americans with Disabilities Act (ADA).
Together, Rhode Island’s developmental disabilities commissioner and the state Medicaid administrator “should have a sight line over the whole experience,” so they are able to see how day supports affects utilization of medical services, Montanaro said.
“It’s pretty easy to look at caseload and utilization and set your budget,” she said. This exercise should be carried out as part of the state’s twice yearly caseload estimating conference, she said. Prior to Governor Raimondo, every administration has set an arbitrary budget target that did not reflective of projected costs, and BHDDH has responded by either lowering rates paid to private providers or running a deficit without worrying about the consequences, Montanaro said.
There’s an assumption in state government that the Division of Developmental Disabilities can lower costs by better managing the utilization of services, she said, but that’s not true.
“The population is “fairly static,” and the needs of clients are stable, she said. Individuals who meet certain criteria are entitled by law to residential services and employment and other social supports.
The only way to reduce costs is to cut reimbursement rates to providers, which has been done in the past, she said.
Montanaro said it appears that prior to her arrival, BHDDH may have created bureaucratic delays to save money by delaying the adjudication of appeals.
“We tried to terminate unfair practices,” she said. “We have a responsibility to plan for the service to clients.” In nearly 18 months at BHDDH, Montanaro said, her team “removed those operational barriers that we found in place here."
"Were they in place deliberately, or were they here because the department was wildly inefficient, with eligibility delays and claims lagging as a result? I won’t speculate on that,” she said.
The amount of time and effort necessary to bring about change in the state bureaucracy leads to “a lot of crisis management,” Montanaro said. “It’s designed to protect institutions from constant, fast change that could come with changes in administration every four to eight years,” she said.
In addition to having a realistic budget, Montanaro said the ideal developmental disability agency would be staffed by experts needed to move reforms forward.
As it is, she said, “the Division of Disabilities has lacked critical leaders in critical roles for all the years far back that I can see.”
For about 16 months, Charles Williams, the outgoing director of developmental disabilities, has split his time between that job and running RICLAS. His professional expertise is in mental health services rather than developmental disabilities, Montanaro said.
As a result of the consent decree - and Montanaro's efforts - BHDDH now has a chief transformation officer, Andrew McQuaide, and has just hired Tracey Cunningham of the James L. Maher Center in Newport as an Employment Specialist.
Funding has been authorized for a quality improvement officer to focus on programmatic improvements for BHDDH staff and private service providers. In addition, a high-level chief operations officer will be hired to round out the leadership team.
As for her own future, Montanaro, 58, said she will take the summer off to recharge. She plans to visit her son and daughter-in-law in France, where the couple are expecting their first child.