The Missouri Waiver: A Means Of
Decreasing Costs And Improvi%

Health Care

We in Missouri are no strangers
to the idea of home andcommunity
based services. Last year we worked
for and signed legislation that
will mark the beginning of a new
era in providing for the needs of
our frail elderly. This legislation
provides for in-home and com-
munity care for elderly persons
who wish to stay in their homes
and who can do so only if they re-
ceive some very basic and very im-
portant in-home services. I believe
that we have proven in Missouri
that `we can provide for a much
betterqualityoflifeandatthesame
time do so at savings.

Likewise,weknowthatthereare
children in our state who face very

similar circumstances. As with the
elderly, these children face a
choice between the lifesaving care
they find in an institution, or the
love and warmth they so desper-
ately need from their families in
their own homes. Children with
multiple and complex handicaps
have a right to the best quality
of life possible. Many of these chil-
dren can realize the maximum in
potential for health, education,
self-fulfillment and self-support,
only with extensive medical, phys-
ical, social and psychological sup-
port. Hospital intensive care units
and nursing homes currently pro-
vide the bulk of these services; but
now we must find new ways to

meet the needs of these children.

Missouri's waiver project is de-
signed to demonstrate the cost-
effectiveness of placing these chil-
dren, who currently must stay in
costly institutions, back into their
own homes and communities. Our
goal is to provide them an oppor-
tunity to grow and develop as nor-
mally as possible in their own
homes as members of their own
families. I believe that home and
community based services can
allow these children this kind of
growth and development, while
providing significant cost savings.

The Omnibus Budget Reconcil-
iation Act approved by Congress in
1981, accelerated the transfer of


fiscal and managerial responsibili-
ties for health programs from the
federal government to the state.
ThisallowstheSecretaryoftheDe-
partment of Health and Human
Services to approve, bywaiver, any
state plan that includes home and
community based servicesas med-
ical assistance. Missouri's waiver
was proposed under these guide-
lines and had been sent to Secre-
tary Heckler. We expect a positive
response from the department in
the very near future.

The second objective is even
more important than the cost fac-
tor. Certainly we expect, and we
think we can demonstrate, the proj-
ect will be cost-effective. But most
important of all, thewaivercanand
will improve the quality of life for
children who can be returned to
their homes. By expanding the
number and scope of servicescov-
ered in a home based setting, chil-
dren can be discharged earlier and
treated in much more comfortable
and more familiar surroundings.
As a result, children will be re-
united with their families, and in
many cases, recovery time can be
shortened as their quality of life
improves.

As the Surgeon General pointed
out, very often children in hospitals
may encounter other diseases and
infections, but when they go back
to their homes they are in an en-
vironment in which they can grow,
not only because of the physical
conditions, but because of the love
and care that a family can give.

The specific services that will be
offered under the Missouri waiver
will apply to needy children who
will be eligible for Medicaid ser-
vices. Some of these services are
already covered under the state
plan. But current limitations ren-
der them inadequate for the exten-
sive service requ irementsfor these
children. With this waiver, the
state will pay for the medical trans-

portation for the children in need.
For example, if the child needs to
go back to the hospital, the state
will pay for the ambulance. The
state will also pay for the home-
maker or chore services to help the
family with homemaking services,
medical equipment and supplies,
physical therapy, and pharmacy
costs.

Christopher S. Bond

These services represent a very
sophisticated level of technology.
Indeed, it's often called High Tech
Home Health Care. They offer the
essential life support systems
these kids need to survive. They
also include the highest level of
skilled nursing care necessary to
maintain the patient's quality of
life.

The concept behind the waiver
was developed while working very
closely with children's hospitals
and medical professionals. Cer-

tainly we in state government
could not have done it on our own,
and we owe thanks to a great many
dedicated physicians and other
health care professionals who
helped us pull together the infor-
mation and outline the standards
wemustfollow.Withtheircombin-
edefforts, wedevelopedtheprinci-
ples and data which are contained
in the waiver. We think the idea of
a group approach is extremely im-
portant, because the children and
their families need the support of
all care providers. Their combined
efforts in bringing together the in-
formation is essential if we are to
identify the children needing these
services, provide the care, and
monitor their progress to the high-
est achievement of their potential
and welfare.

The extensive array of services
made availablethrough this waiver
would enable the children to re-
ceive quality care in their own
homes. They extend not only to the
child, but to the entire family unit.
This is a very important aspect of
the waiver because it recognizes
that not only does the patient have
special needs, but that the entire
family also must cope with these
responsibilities. The waiver alone,
however, does not make all of this
happen. Many other services are
needed if the programs are to be
successful. We must have support
from the medical community in-
cluding hospitals, physicians,
home health agencies, medical
equipment providers and a whole
host of medical personnel, as they
try to adapt to the changed life-
style that accompanies the pres-
ence of a handicapped child in the
home.

Studies have shown that fami-
lies of handicapped children appear
to be particularly vulnerable to the
experience of stress. In fact, in some
cases, this stress factor is so great
that some families have felt that


they have had no choice but to seek
institutional care fortheir children.
As a result, we must find new
methods of returning these chil-
dren to their own homes, which
will alleviate the stress as much as
possible. We believe and expect
this is precisely what the Missouri
waiver will do.

In addition, as I indicated earlier,
the waiver will be a cost-effective
mechanism for delivering alterna-
tive sources of care to these chilr
dren. Implementation of the waiver
provisions will save approximately
$3500 per child over a year's time.
This translates into savings for the
taxpayer, while clients are provid-
ed better services more efficiently
in their home surroundings.

We speak of the waiver of being

the magic instrument which will
save money and ensure quality.
Obviously, it's a start, and when
you're dealing with government,
you're going to have paperwork.
Still, it is what this paperwork rep-
resents that is important. It repre-
sents a unified approach for chil-
dren and their parents to be suc-
cessfully reunited so that each
child can reach his or her full po-
tential in an environment most
conducive to recovery. Without the
expertise of the physician, the
medical needs of the child cannot
be totally identified. Without the
case manager, the various essen-
tialone-on-onesupporttothechild
and the family would be missing.
Without the support and coopera-
tion of the service providers, the

entire program would not be pos-
sible. It's through their knowledge
and care that these children are
able to be treated in their homes.
And obviously, without the care,
love and understanding of the par-
ents, these children would not
even have a small hope of sucess-
fully recovering, going on to lead
fulfilling lives.

It's this unity of purpose that
makes this program a success.
When all the concerned parents
are striving for a common objec-
tive, many worthwhile goals can
be obtained. I believe the goals
contained in Missouri'swaiver are
very humane and certainly with
your continued efforts and help
they are attainable and they will
be obtained. 0