See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265022086 Challenges to Sustaining California's Developmental Disability Services System Article CITATIONS READS 0 33 4 authors, including: Daphna Gans Gerald Kominski University of California, Los Angeles University of California, Los Angeles 24 PUBLICATIONS   898 CITATIONS    136 PUBLICATIONS   2,164 CITATIONS    SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: UCLA School of Public Health-Health Services Research & Policy Analysis Doctoral Dissertation View project California 1115 Waiver Evaluations View project All content following this page was uploaded by Gerald Kominski on 20 November 2014. The user has requested enhancement of the downloaded file. March 2011 Challenges to Sustaining California’s Developmental Disability Services System Daphna Gans, Anna C. Davis, Christina M. Kinane, and Gerald F. Kominski SUMMARY: California’s developmental disability services system is currently facing severe budget reductions as part of Governor Brown’s efforts to close the state’s budget gap. For more than a decade, guaranteeing adequate funding for these services has been challenged both by a dramatic increase in the number of individuals eligible for these services and by limited resources, rate freezes, and inadequate transparency in resource allocation. These factors threaten the financial solvency of service providers, potentially resulting in decreased access to high-quality care and increasing the cost of care for the state. As the only state in the nation that has established an entitlement for developmental disability services, California must pursue multiple strategies in order to meet the goals of this entitlement and to ensure both adequate and equitable access to high-quality and cost-effective services. This policy note discusses the background of California’s developmental disability services and identifies the challenges facing this system. It recommends that the state adjust frozen rates for services, adopt equitable and transparent vendor payment systems, and maximize the efficiency of the current system of service provision, among other policy solutions. Background family caregivers), supported living, supported employment, and work activity programs.3, 4 The statutory framework for provision of services to Residential settings primarily include Intermediate Care individuals with developmental disabilities in Facilities (ICFs) and Community Care Facilities California was established in 1969 by the Lanterman (CCFs), both providing care at various levels of need, Developmental Disabilities Services Act and its later as well as State Developmental Centers (SDCs), which amendments (“The Lanterman Act,” Welf. & Inst. are residential facilities providing habilitation and Code §4500, et seq.). This bill defines a basic right of treatment.5 The majority of consumers live and receive individuals with developmental disabilities to receive, services in the community. In 2007, those receiving and a corresponding obligation of the state to provide, services resided in one of the following settings: with a regional community-based services that “maximize family member or guardian (73%), a CCF (12%), an opportunities and choices in living, working, learning, independent or supported living program (9%), a and recreating in the community” (Welf. & Inst. Code skilled nursing facility or ICF (4%), an SDC (1%), or §4640.7).1 Services for individuals with developmental another type of setting (1%).6, 7 disabilities are an entitlement in California and are intended to minimize institutionalization and enable Responsibility for implementation of the services independent living within the least restrictive authorized in the Lanterman Act is divided between the environment possible (Welf. & Inst. Code §4502). Department of Developmental Services (DDS) and twenty-one private, nonprofit Regional Centers (RCs).1 Services can be generally categorized into three core The DDS system, which was allocated about $4.5 types: residential care, community programs, and billion in the 2010–2011 state budget, currently serves transportation services.2 Community programs provide more than 244,000 consumers. That number is expected a variety of services, including day programs (e.g., to grow to nearly 252,000 consumers in the 2011–2012 social skills training, behavioral intervention, and fiscal year.1, 8-10 In budget year 2009–2010, 52 percent therapeutic treatments), in-home respite (relief for of the RCs funding came directly through the state’s 2 general funds, with the remaining resources funded single business entity, as one entity receives multiple through a mixture of federal and state sources, as well unique vendor numbers for each service type provided other sources such as parental fees.6, 11 The DDS acts as within each RC.14 Of the 45,000 vendors who provide the budget intermediary with an oversight capacity, services, 40 percent are private nonprofits and for- while the RCs are delegated the day-to-day profit agencies, and 60 percent are parents or other responsibilities of determining diagnosis and eligibility, family members of DDS consumers.6 Nonprofits are as well as carrying out the state’s obligation to provide prevalent in the vendor community: among the 100 care to eligible individuals.2, 12 The California Welfare business entities with the highest level of total RC and Institutions Code defines “developmental expenditures during fiscal year 2008, 51 percent were disability” as a disability that originated before the nonprofits, accounting for more than 1,130 vendors individual was eighteen years of age, continues or can and over $466 million in purchased services.14, 15 be expected to continue indefinitely, and constitutes a Vendors of supported employment programs are substantial disability for the individual. To be eligible required by statute to have nonprofit status (Title 17, to receive DDS services, an individual must have been CCR §54351). diagnosed by an RC or, if under three years old, must exhibit substantial developmental delay.6 Challenges Once eligibility is established, the RC conducts an The developmental disability service system faces two individual planning process and develops an Individual distinct types of challenges: (1) the increasing need for Program Plan (IPP) or, for a consumer younger than and cost of services, and (2) limited resources, rate three, an Individualized Family Service Plan (IFSP). freezes, and insufficient transparency in resource This process involves setting specific goals and allocation. determining which services will best meet the individualized needs and preferences of the consumer. Growing Needs and Costs The RC then engages in service coordination to ensure that services in the IPP or IFSP are obtained. This can Growth in DDS Population Served in the Community be either through generic agencies (publicly funded agencies that have a legal responsibility to serve all The overall number of DDS consumers has increased members of the general public – for example, Medi- by 57 percent since 2000, while the general population Cal, County Department of Health, and In-Home of California has grown by only 14 percent during this Supportive Services), natural supports (family members same period.8, 16 Specifically, the population of children or friends), or if no generic agency is available, through under the age of three receiving early start services in purchase of services from vendors using RC funding.1, 6 the community has increased by 62 percent, and the population of DDS consumers over age three who are Among those consumers served in the community in served in the community has increased by 53 percent.8, 2007, about 78 percent received RC-funded services.7 17, 18 The addition of new consumers accounts for 43 Services are provided to the consumer free of charge, percent of the growth. However, the growth in the with these exceptions: an income-based family cost population served in the community, and the associated participation requirement for individuals ages three to costs of such care were also impacted partially by the seventeen who are living at home and receiving respite, implementation of a planned closure of SDCs. The day care, or camp services; and family cost sharing for population of DDS consumers served in these facilities 24-hour out-of-home placement of children.6 has decreased by 48 percent since 2000.8 In 2007, the The RC process of selecting vendors, referred to as average per capita cost of care in SDCs was almost “vendorization,” consists of identification, selection, $276,000, compared to $16,165 in the community.6 and utilization of service providers.13 The Lanterman Moving SDC residents to community care settings Act and Title 17 of the California Code of Regulations accounted for 24 percent of RC expenditure growth (Title 17, CCR) require that the vendorization process between 2000 and 2007.6 consider the following: (1) a provider’s ability and past success in delivering quality services; (2) the existence Booming Autism Rates of appropriate licensing, accreditation, and Ongoing increases in the prevalence of individuals certifications; (3) the cost of providing services of diagnosed with Autism Spectrum Disorders (ASD) comparable quality; and (4) the consumer’s choice of have led the Centers for Disease Control and provider.2 Often, multiple vendors operate under a 3 Exhibit 1. Growth in California population with autism versus three other major developmental disabilities and the “fifth category,” 2000–2010 Notes: Developmental disability groups are not mutually exclusive, due to potential duplication of individuals across diagnostic categories. The “fifth category” refers to disability conditions found to be closely related to mental retardation or to require similar treatment (Welf. & Inst. Code §4512). Source: Authors’ analysis of data provided by Department of Developmental Services Data Extraction Unit; 2011. Prevention (CDC) to declare ASD an urgent public school districts rather than by DDS, whereas adults health concern.19 In California, the number of people have an increased need for community services or with autism served by DDS has grown by 283 percent residential care.7, 21 Specifically, in fiscal year 2006– since 2000.8 However, the annual growth rate has been 2007, the average per capita cost of serving individuals steadily declining since 2003, indicating a potentially with autism ages twenty-two to forty-one was 203 lower expected growth in the next decade. Since 2003, percent higher than the per capita cost for individuals the incidence of other major developmental disabilities with autism ages three to twenty-one (Exhibit 2).7 has also increased, among them: mental retardation (34%), epilepsy (21%), cerebral palsy (19%), and the Aging of the Current DDS Population with Autism “fifth category,” representing conditions resembling The age composition of the DDS population diagnosed mental retardation or requiring similar treatment with autism is expected to shift in the coming years, (122%).8 Additionally, the proportion of DDS affecting the cost of services. In 2007, 83 percent of the consumers with higher needs due to dual diagnoses DDS population with autism was concentrated at ages (mental illness and developmental disability) increased three to twenty-one; 13 percent were ages twenty-two by 48 percent between 2001 and 2006. 6, 20 to forty-one; 4 percent were ages forty-two to sixty- Expenditures for individuals with autism are higher one; and 0.2 percent were age sixty-two and older.7 As than those for individuals with any other type of the large proportion of individuals ages three to twenty- developmental disability in every age group. In the one transition to adulthood, DDS will face a substantial provision of services to consumers with autism, the cost cost burden.21 Because information is not readily of serving children is lower than that of serving adults. available on the severity of the condition for each The reason for this differential is that children are likely individual consumer, it is difficult to predict with to live at home and use educational services paid for by precision the increased cost of DDS services as consumers age. 4 Exhibit 2. Average annual expenditure per consumer by age group for those with autism and those without, Fiscal Year 2006-2007 Source: Department of Developmental Services, Factbook, 11th Edition, 2008, State of California, Department of Developmental Services. Prolonged Life Expectancy of the Eligible Population reductions to the DDS system.9, 22 As this policy note and Aging of Informal Caregivers goes to press, budget discussions indicate a potential reduction of more than $500 million in the total budget Medical advances across the lifespan and improved available for developmental services, including a $174 health care have resulted in increased life expectancies million cut to be achieved through potential among individuals with developmental disabilities. As implementation of statewide purchase of service a result, consumers require services for longer periods standards, among other cuts.23 Additionally, it is of time, as well as services at a higher intensity during proposed that current rate freezes be extended and their later years of life. Additionally, the aging of the vendor payment reduced by 4.5 percent through June eligible population is accompanied by the aging of their 30, 2012.10 Moreover, a 10 percent Medi-Cal rate cut is caregiving parents, leading to an increased level of proposed, which will impact payments to vendors need for supportive formal services. When a caregiver reimbursed via the Medi-Cal fee schedule.24 Finally, dies, a DDS consumer likely requires an alternative the loss of federal matching funds will further reduce residential setting at a high cost.6 overall available funds. Limited Resources, Rate Freezes, and Insufficient Complex and Fragmented Rate Setting Transparency in Resource Allocation The reimbursement rates for services provided by Recent Budgetary Cuts vendors are determined through differing rate-setting methodologies for different types of services, as The current state fiscal crisis further exacerbates DDS’s stipulated in Title 17 CCR. Reimbursement rates may increasing budgetary pressure, given the growing be based on a statute-defined rate, or they may be demands for care and the rising costs of that care. reached via a variety of cost-based methodologies, Although it has not yet been enacted, Governor “usual and customary” rates, and rates negotiated Brown’s budget currently proposes substantial between vendor and RC. 25, 26 The “usual and 5 customary rate” provision requires that rates reflect Can California Continue to Provide High- what is “regularly charged” by the vendor for the specified service to non-RC clients (Title 17, CCR Quality and Cost-Effective Developmental §57210). In those cases where none of the above rate- Disability Services? setting processes is applicable, the vendor receives a negotiated rate from the vendoring regional center Potential Loss of Equitable Access to High-Quality (Title 17, CCR §57300). Care The continued financial health and operational capacity Insufficient Transparency and Accountability and of RCs and their vendor network are necessary to the Potential Non-Equitable Negotiated Rates state’s ability to provide high-quality services to An amendment to the Lanterman Act passed in July individuals with developmental disabilities. 2009 established a requirement that RCs select the least Widespread rate freezes and payment reductions may costly available provider of a comparable service; the ultimately harm vendors’ financial viability. It has been requirement to use cost-effective services is repeated in shown that in response to increasing costs without several parts of the act. However, the concepts of corresponding rate increases, vendors offer lower pay “cost-effectiveness” and “comparable services” are not to staff than do comparable employers. Given this defined in the statute, making it difficult to establish competitive disadvantage, vendors struggle to recruit clear guidelines for vendor selection.2, 6 and retain direct-care staff, and newly hired staff often have less experience and lower levels of education than Additionally, RCs are charged with the authority and those whom they are replacing.27 discretion to establish vendor payment rates for 96 of 155 active service codes, which account for almost half Turnover among service providers is not predicted by of total purchased services.5 Should negotiations be low wages alone, but rather by a complex set of factors, required, the law and regulations do not mandate their including benefits such as paid time off and vacations.28 format, content, or quality, nor do they require the RCs The shortage of qualified direct-care personnel may to document the negotiation process.2 The California impact the ability of providers to adequately meet the State Auditor has noted alarming examples of poor or needs of service recipients.27 The current frozen rate nonexistent documentation of the RC rate-setting levels require vendors to absorb increasing implicit and process, as well as cases of allegedly unethical rate- explicit costs, thereby threatening vendors’ financial setting practices, failure to comply with Title 17 CCR solvency. Specifically, the rate freezes instituted in regulations, and apparent disregard for the established 2002 have neglected the 22 percent increase in implicit rate freeze.2 Lack of documentation may result in costs due strictly to inflation.29 negotiated rates that may not be cost-effective and Financial challenges that restrict the ability of equitable. nonprofits to operate as DDS service providers are of special concern, given their prevalence in the vendor Ongoing Rate Freezes community and their mandated involvement in Since 2003, rates for many services have been frozen or providing supported employment. In some settings, restricted by the state, and on July 1, 2008, negotiated such as nursing homes, nonprofit organizations have rates with all preexisting vendors were frozen.6 Rates been shown to provide better quality care than for- for new vendors established after that date are required profit facilities.30, 31 To be consistent with their to be less than or equal to the lower of either the underlying mission to provide services to those in need, statewide or regional average rate for the service type nonprofits are likely to offer services to any consumer, in question; once they have been set, these rates are regardless of profitability. In contrast, for-profits are also subject to the freeze.2 Finally, existing law require potentially able to risk-select consumers with lower that RCs reduce by 3% all vendor payments for perceived levels of need, or to minimize expenditures services delivered between February 1, 2009, and June to maximize revenues.31, 32 Among the 51 large 30, 2010, and by 4.25% all vendor payments for nonprofits within the top 100 business entities in the services delivered between July 1, 2010, and June 30, DDS system in 2008, 16 (about 30%) reported an 2011.10 True operating costs of vendors are unknown, operating deficit, substantiating concern about their and current rates for some providers may not financial viability.15 Such threats to the supply of correspond with operating costs. services may fundamentally restrict consumer access and counteract the entitlement function of the Act. 6 Exhibit 3. Operating Deficits among the 51 Highest Policy Recommendations Expending Nonprofits in the DDS System, 2007 and 2008 Based on our analysis of the challenges facing the California developmental disability services system, we propose the following policy recommendations to ensure both adequate and equitable access to high- quality, cost-effective services throughout California. Adjust Frozen Rates to Ensure Vendors’ Financial Viability and Continued Access to Care Establishing a fee schedule that is informed by thorough cost-based analysis and that incorporates adjustments for the increasing cost of service provision would allow vendors to sustainably maintain operations by limiting undue fiscal strain. A cost-based analysis recognizes the inherent variability in consumer needs -- where more severe conditions require more intense and expensive services -- and it also engages stakeholders in the rate-setting process. Furthermore, the cost statements required for rate- setting should reflect the true costs of providing efficient and high-quality services, as required by the Source: Authors’ analysis of IRS Form 990 tax filings for 51 nonprofits California Welfare and Institutions Code §4690. This within the 100 highest expending business entities in the DDS system in FY08, based on data generated by Department of Developmental Services would allow for the consideration of any mechanisms Data Extraction Unit; January 2009. that have been employed by vendors to reduce costs in a rate-restricted environment in order to maintain solvency. The inclusion of an explicit adjustment for Cost of Vendor Financial Insolvency to the State input price inflation, such as the Consumer Price Index (CPI), would mitigate threats to access by recognizing Threatened financial insolvency of vendors, given rate the ongoing cost increases faced by vendors. freezes and inadequate reimbursement levels, may result in higher costs of care for the state. For example, Adopt Equitable and Transparent Vendor Governor Brown’s budget proposes a 10 percent rate Payment Systems cut for all Medi-Cal providers, including ICFs, beginning in June 2011. This rate cut would come on Promote Transparency and Accountability top of the 2009 freeze on reimbursement rates for these facilities.24, 33 Almost 9,000 DDS consumers lived in The California State Auditor’s report of 2010 skilled nursing facilities or ICFs in 2007.7 recommended establishing a uniform and transparent rate-setting process to improve cost effectiveness; that Some predictions suggest that as many as 5 percent of recommendation resulted in initial efforts by the DDS ICF beds will be lost as a result of rate cuts, requiring to implement reforms. However, the scope of the transfer of these consumers to other care facilities.34 reforms focuses on a directive requiring RCs to Should these consumers need to be transferred to “document how they determine that the rates they SDCs, which are more costly to the state, a portion of negotiate or otherwise establish are reasonable for the the savings achieved by reducing the SDC population services to be provided.”2 Additional efforts to increase over the last decade may be lost. The annual per capita transparency in vendor selection and vendor payment cost of care is about $70,000 for individuals residing in are needed, and oversight of the process at every level ICFs, compared to almost $276,000 for those in should be increased.2 For negotiated rates to properly SDCs.6, 34 Although half of the cost of care in both demonstrate cost-effectiveness, standard definitions of settings is offset by federal reimbursement, the the terms “cost-effective” and “comparable services” increased cost to the state would be significant. should be developed.7 A clear, uniform definition of 7 these terms will facilitate clear guidelines of vendor independent standards currently decided at the RC selection.2, 6 level.22 The development of such standards should be done in the context of a careful examination of Extend Comprehensive Vendor Cost Reporting successful mechanisms that promote the delivery of Requirements to All Service Types high-quality equitable services rather than in the context of budget reduction efforts. Such standards Standardized, comprehensive reporting of finances and should not be utilized to impose artificial caps on utilization by both vendors and RCs will lay the reimbursement rates, to eliminate service, or to limit groundwork for a more efficient, cost-effective, and the flexibility or the availability of appropriate services transparent system. One of the major obstacles to and supports as determined in the IPP. reconciling the cost of services with shrinking budgets is the lack of detailed data on current costs for service Identify and Use Additional Funding Sources types that at present do not require cost reporting. Enhanced reporting can support appropriate cost-based Sources of additional funding outside of the DDS reimbursements, such as those implemented by the budget should be maximized. Existing regulations Federally Qualified Health Center (FQHC) program.20 require RCs to use generic services before purchasing A comprehensive cost-reporting mechanism to inform services, but a clear methodology ensuring compliance RC budget processes and rate-setting negotiations can is lacking.6 Additionally, federal Medicaid facilitate transparent evaluations of vendor and service reimbursement should be maximized in a number of sustainability, as well as reduce variability and inequity DDS service areas, including the Home and in vendor payments. In the setting of a severe budget Community–Based Services (HCBS) Waiver.35 The deficit statewide, cost documentation would be state has undertaken some efforts to enhance federal valuable in informing difficult state budgetary reimbursement, such as increasing the enrollment cap decisions. under the HCBS waiver in 2008.9 However, in 2007, as many as 1,100 consumers were being served in Implement a Standard Negotiated Rate System facilities that were not eligible for waiver participation, representing a lost opportunity for federal A standard rate system for services that currently do not reimbursement of as much as $10.7 million.6, 35 Further have a particular rate-setting method, such as benefit can be gained by ensuring service coordination transportation and behavioral services, would promote with private insurance plans to prevent duplication of equity between vendors and service codes, limit benefits.36 Finally, it has been suggested that the family wasteful spending, and protect vendors with less cost-participation plan, currently in place for a small financial resiliency, including nonprofits and the number of services, should be expanded to include parents of consumers. additional services.6, 9 However given the very high cost of the vital services required by many of the individuals Maximize System Efficiency served by DDS, it is essential that income levels or other qualifying criteria be carefully evaluated to Develop Efficient Service Provision prevent catastrophic financial consequences for Conducting real-time reviews of opportunities to families. minimize the marginal costs of additional DDS consumers and to eliminate inefficient service Conclusion selection, without compromising the quality of care, could assuage the reduction in overall funding. For California’s DDS system faces considerable challenges instance, if group-setting care can be demonstrated to due to rate freezes that have extended for more than a be as effective as individual-setting care, RC strategies decade, despite ongoing growth in both the demand for should maximize group service provision.6 services and in the underlying costs of providing Additionally, establishing a more competitive bidding services. The policy recommendations presented above process for vendor selection or a “preferred provider” suggest that the legislature and governor need to give system might enhance efficiency.6 serious consideration to finding additional solutions to these challenges. Governor Brown’s proposed trailer bill language for the 2011–2012 budget discusses the establishment of statewide purchase-of-services standards in lieu of the 8 Author Information Daphna Gans, PhD, is a research scientist; Anna C. Davis, MPH, is a senior research associate; and Christina M. Kinane, MPA, is a research associate, all at the UCLA Center for Health Policy Research. Gerald F. Kominski, PhD, is Associate Director of the Center and professor of Health Services in the Department of Health Services, UCLA School of Public Health. Acknowledgments This policy note was supported through a generous donation from Ralph and Shirley Shapiro. We wish to thank Dylan Roby, Kathryn Kietzman, and A.E. Benjamin for their valuable comments. References 1. Oversight of California's Regional Centers: Ensuring Integrity, Transparency, and Best Practices in a Challenging Fiscal Environment. Senate and Assembly Committees on Human Services, Background Briefing Paper. Also, California State Auditor Report 2009-118 -- Presentation Document. Sacramento: November 4, 2010. Available from: http://www.assembly.ca.gov/acs/Committee/C13/Background_Paper_RC_OversightFinal110410.pdf and http://www.bsa.ca.gov/pdfs/other/testimony_20101104_dds.pdf 2. California State Auditor. Department of Developmental Services: A More Uniform and Transparent Procurement and Rate- Setting Process Would Improve the Cost-Effectiveness of Regional Centers. Report 2009 -118. August 2010. Available from: http://www.bsa.ca.gov/pdfs/reports/2009-118.pdf. 3. For more information on the various services available to DDS consumers, please visit http://www.dds.ca.gov/RC/ProgramSvcs.cfm. 4. California Department of Developmental Services. Information About Programs and Services. Cited 1 March 2011. Available from: http://www.dds.ca.gov/RC/ProgramSvcs.cfm. 5. California Department of Developmental Services. Living Arrangements for Persons with Developmental Disabilities. Cited 1 March 2011. Available from: http://www.dds.ca.gov/LivingArrang/. 6. California Department of Developmental Services. Controlling Regional Center Costs. 2007. Available from: http://www.dds.ca.gov/publications/docs/controllingrccosts2007.pdf. 7. California Department of Developmental Services. Factbook (11th ed.). Available from: http://www.dds.ca.gov/factsstats/docs/factbook_11th.pdf. 8. Authors' analysis of data generated by the DDS Data Extraction Unit, January 2011. 9. Taylor M. The 2011-2012 Budget: Options to Achieve Savings in the Regional Center System. California Legislative Analyst's Office. 2011. Available from: http://www.lao.ca.gov/analysis/2011/health/regional_center_020111.pdf. 10. Brown E., Dooley D., and Delgadillo T. California Department of Developmental Services 2011-2012 Budget Highlights. Available from: http://www.dds.ca.gov/Budget/Docs/2011_12DDSHighlights.pdf. 11. Department of Developmental Services. November Estimate: Local Assistance for Regional Centers, 2011-2012 Governor's Budget. Available from: http://www.dds.ca.gov/Budget/Docs/2011_2012RCNovemberEstimate.pdf. 12. The DDS’s oversight functions are designated under the Lanterman Act and through California’s responsibilities under the Federal Medicaid Home and Community-Based Services (HCBS) Waiver. Oversight responsibilities are centered on monitoring and support of RCs. In a paramount decision from the Association for Retarded Citizens--California v. Department of Developmental Services (ARC v. DDS), the California Supreme Court also noted that the DDS “is responsible for developing uniform systems of accounting, budgeting, and reporting, setting the rates for out-of-home care, and auditing and paying funds to the regional centers.” 13. California Department of Developmental Services. Vendorization Process Overview. Cited 14 December 2010. Available from: www.dds.ca.gov/Rates/Vendor_Process.cfm. 14. Authors' analysis of data generated by the DDS Data Extraction Unit, January 2009. 15. Authors' analysis of 2008 IRS Form 990, Tax Filings for Nonprofits. Accessed from the GuideStar Nonprofit Directory. Available from: www.guidestar.org. 16. State Census Data Center Products. Cited 14 February 2011. Available from: http://www.dof.ca.gov/research/demographic/. 17. Lanterman Regional Center. Summary Changes Included in Budget Trailer Bill for 2009-2010 Budget. 2009. Available from: http://www.elarc.org/pdf/Summary%20Changes%20in%20Budget%20Trailer%20Bill%20as%20of%20June%2029%20200 9.pdf. 18. The trailer bill language for the 2009-2010 budget limited eligibility for intervention among children younger than 24 9 months old and created a new category of service called “prevention.” 19. Rice C. Prevalence of Autism Spectrum Disorders: Autism and Developmental Disabilities Monitoring Network, United States, 2006. Online 2009. Cited 14 January 2011. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm. 20. Kang T. and Harrington C. Variation in Types of Service Use and Expenditures for Individuals with Developmental Disabilities. Disability and Health Journal. 2008: 1(1): pp. 30-41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21122709. 21. Acumen LLC. Trends in DDS Expenditures: Impact of Cost-Containment Measures. Report Submitted to the California Department of Developmental Services. 2008. Available from: http://www.cdcan.us/budget/2008-2009/DDS_expenditures- v28.pdf. 22. Brown E. 2011-2012 Governor's Budget Summary. Sacramento, California: 2011. Available from: http://www.ebudget.ca.gov/pdf/BudgetSummary/FullBudgetSummary.pdf. 23. Senator Mark Leno - Chair. Budget Conference Committee Action Quick Summary. California State Senate Committee on Budget and Fiscal Review. 2011. Available from: http://www.sen.ca.gov/budget/conf2011/372011ConfComActionQuickSummary.pdf. 24. California Legislative Analyst's Office. Summary of LAO Findings and Recommendations on the 2011-12 Budget: Medi- Cal Payment Reductions May Be Risky. Available from: http://www.lao.ca.gov/laoapp/budgetlist/PublicSearch.aspx?PolicyAreaNum=0&Department_Number=4260&KeyCol=294 &Yr=2011. 25. Cost elements include basic living needs, indirect costs, direct supervision, special services, and a proprietary fee (which covers fixed assets). (Title 17 CCR §56910) 26. For supported employment services, standard rates are established by law (Title 17 CCR §58881). Rates for services similar to those covered by the Medi-Cal program are established by the Department of Health Care Services (DHCS) and cannot be lower than Medi-Cal's established rates. For community-based day care programs, independent living services, and work activity programs, DDS uses a rate-setting procedure based on staff-consumer ratios and vendor cost statements. DDS uses an alternative rate-setting methodology that considers vendor cost statements, income, and the permanent rates established for comparable vendors to set the rates for in-home respite care agency vendors (Title 17 CCR §58100). Rates for CCFs are established through the Alternative Residential Model (ARM) rate-setting methodology, based on median costs per consumer per month and varying by levels of care and geographic location (Title 17 CCR §56910). Other residential services provided by ICFs are funded by Medi-Cal through the Department of Health Care Services and are eligible for 50 percent reimbursement from federal funds for those ICF residents who are Medi-Cal eligible. Supported living services and Family Home Agency services are required to be negotiated on a contract-by-contract basis with the RCs (Title 17 CCR §58660-§58663, §56082). Transportation service rates are either set through “usual and customary” methodology or are negotiated (Title 17 CCR §58540). 27. Adults with Developmental Disabilities Post Hearing Report on the Adequacy in Direct Care Staffing. Joint Legislative Audit Committee. Sacramento, Calif.: 1998. 28. Wheeler B., Kurtz D., and Smith T. Evaluation of the Impact of WIC Section 4681.4 (Rate Increase) on Staff Turnover for Direct-Support Workers in Licensed Community Care Facilities for People with Developmental Disabilities, 1998-2000. 2002. Submitted to the California Department of Developmental Services by University of Southern California Affiliated Program. Available from: http://www.dds.ca.gov/DSPT/Docs/Turnover_Study_2002.pdf. 29. Consumer Price Index Inflation Calculator. Cited 1 March 2011. Available from: http://www.bls.gov/data/inflation_calculator.htm. 30. Gertler P. and Kuan J. Does It Matter Who Your Buyer Is? The Role of Nonprofit Mission in the Market for Corporate Control of Hospitals. Journal of Law and Economics. 2009: 52(2): pp. 295-306. 31. Comondore V.R., Devereaux P.J., Zhou Q., et al. Quality of Care in For-Profit and Not-For-Profit Nursing Homes: Systematic Review and Meta-Analysis. BMJ. 2009: 339: pp. b2732. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19654184. 32. Frumkin P. and Andre-Clark A. When Missions, Markets, and Politics Collide: Values and Strategy in the Nonprofit Human Services. Nonprofit and Voluntary Sector Quarterly. 2000: 29(1): pp. 141-163. 33. Schwarzenegger A., Belshé K., and Delgadillo T. 2008-09 Governor’s Budget Highlights, California Department of Developmental Services. January 2008. Available from: http://www.dds.ca.gov/budget/Docs/0809_GovernorsBudgetHighlights.pdf. 34. California Association of Health Facilities. Issue Brief: Protect and Preserve Medi-Cal Funding for Medi-Cal Intermediate Care Facilities for Persons with Developmental Disabilities. January 2011. Available from: http://www.cahfdownload.com/cahf/advocacy/ISSUEBRIEF_DDCuts.pdf. 35. PNP Associates. Developmental Disabilities in California: An Analysis of Federal Revenue Opportunities. 2003. 36. Lake T., Sasser A., Young C., et al. A Snapshot of the Implementation of California's Mental Health Parity Law. Mathematica Policy Research Inc., Editor. Cambridge, MA: 2002. Available from: http://www.mathematica- mpr.com/PDFs/snapshot.pdf. View publication stats