Wednesday, December 22, 2004

Self-Direction, Episode II

In which Regional Centers and vendors are predicted to decline in importance as a result of SD.

First of all, I expect to remain in business and well-fed. The decline in importance probably won't be drastic and in most cases is likely to focus much of the system more on core mission. Overall, it's hard to predict whether shrinking budgets and costs will balance out in favor of, or to the detriment of the agency.

I think it's safe to assume that vendors will shrink as a proportion of the whole. Regional Centers will have to as well to make the whole reform work. The benefit from this change is, many clients receive professional assistance from vendors because there are no natural resources in the community able to provide needed help for free. Clients are able to employ unvendored, unlicensed alternatives for support that requires little training, oversight or infrastructure. This can remove lower-value activities from the responsibilities of vendors to provide and regional centers to monitor.

Please note that some of the savings will come from a reduction in the need for source documentation and process-focused quality assurance. I'm trusting that the reduced need for these types of scrutiny will result in a reduction in them. If not, it will be an unnecessary missed opportunity to improve the system both in terms of quality of benefit and cost. Plus, the people who think I'm preposterously gullible will have been right again.

A final note on shrinking service providers- and I think I am hopelessly naive here, in order to sustain the best of what the system has to offer, I think it would be a good idea to reduce pressures on rates and the POS and Operations budgets of Regional Centers by reducing agency funding by more than half but less than all of the realized savings. The high-value activities that agencies will continue to manifest have been underfunded for a long time and can have greater impact through more robust funding.

Monday, December 20, 2004

Self-Directed Services: Episode I

In which Doug rants about what real reform is and explains why Self-Direction qualifies.

OK, so the first thing is to distinguish real reform and "reform." The analog for me is to construction. Smarter architecture and better carpentry technique can allow structures to accomplish new things, find new uses or maintain the old function with fewer materials. We kind of already read in the papers about what happens when builders try to do things the same way with lesser materials.

The parental co-pay starting in January is not real reform, it's the opposite, because it adds costs not related to the function of the system in order to change who pays. More cost, no added benefit to the client.

The Statewide Purchase of Service Standards (POSS) that I expect to be proposed in January are likewise, not real reform. I expect them to raise the cost to the State and reduce benefit to society. My prediction is reasonable but unsupported by facts as is the opposite prediction. In a clear and concrete way, the POSS proposal is an arbitrary attempt to use less lumber in building an identical structure. The real savings or added cost depends on how soon it collapses and which attorneys the injured employ.

Self-direction, on the other hand, is better architecture. One of the chief inefficiencies in our system is what economists call the "Principal-Agent problem." That means that the people making decisions have different goals and incentives than the supposed beneficiaries. The inefficiencies that economists connect with this problem are, yup, waste, fraud and abuse. Basically, resources are diverted from their purpose to serve the goals of the agent (i.e., service coordinators, life quality assessors, direct-care staff, portly executive directors, etc.) Please note, this isn't always (or often) the intention of bad people, but often natural result of committed people who are worried about the alligator biting their bootheel and climbing their leg.

Under self-direction, the Principal (the client) is significantly more the agent than is currently the case. Service Providers are free to set rates and clients are free to pay them or to substitute a cheaper and sufficient alternative. The only reasonable outcome to expect is that the principal will seek a cost-effective array of services and reduce the incidence (and cost) of bad service selection by service-coordinators, inflated service provision by vendors, unrealistic expectations by life-quality assessors and clients' rights officers, etc.

The principal-agent problem persists, with the positions reversed, when you consider the goal to be stewardship of taxpayer dollars (a stated goal of the Lanterman Act.) Because clients and their families bear little or none of the cost of services under the current delivery model, they have no incentive to accept insignificant reductions in benefit in exchange for substantial cost savings. (In theory, the family share of cost assessment due to begin in January was meant to reduce this problem and maybe in another post I'll write about it's flaws as a solution.) In this case the State or the taxpayer or the system is the principal and the client/family member is the agent making decisions.

Consider: One cost that my agency bears (and therefore the State) is client absenteeism. If I send someone to work with a client who is not there, no service is delivered and I don't bill but I do pay staff for time and mileage and therefore I am restricted in my ability to lower my rate. Another cost related to providing services (this may be limited to specialized services like ours) is the cost of serving different individuals in different places. When staff see three different clients in an 8-hour day, there is often one hour of travel time during which there is no benefit to the client.

After last year's Self-Determination Conference I grabbed 10 files at random and calculated that a 100% reduction in client absenteeism and a 50% reduction in travel-time would amount to a 12% reduction in our costs for those 10 clients. Under the current delivery model, it would be illegal (I assume) and unethical (I'm certain) to offer to pay clients for perfect attendence and to work with staff less often for longer sessions. Granted, some clients may have sound and irremovable cause to miss sessions or to see us more often for less time. For the others, however, under a self-directed services model, I could absolutely offer a discount in exchange for consideration.

There's another available source of systemwide savings that would improve the benefits to clients. Because this system does not evaluate outcomes, nor supervise services, the focus of system's quality assurance process amounts to primarily a review of proxy documentation. The assumption is that if a thorough review of your documentation supports the the presumption of a quality program, then you may be alright.

This leads to two inefficiencies vis-a-vis either principle stakeholder groups- the clients and the taxpayers. Because our paperwork is the messenger of quality, vendors and regional centers dedicate probably more effort to turning out (or reviewing) good-lookin' sheets than actually improves our services. My reckoning has always been "they don't know how we're doing so they have to know what." In theory, when the person controlling the funds is the person who benefits (or not) from what they buy, the quality assurance currently being done can focus on measures of success rather than measures of effort. That means a shift in incentive to providers from describing services well to providing good service. As a consequence, resources will be redirected in the same direction. A client willing to continue paying for services means almost the same thing as a thorough documentation of effort and should be cheaper to maintain.

More client benefit, less cost, more sustainable agencies. Real reform.

Stay tuned later this week for the next episode.

Friday, December 17, 2004

Self-Directed Services: The mini-series

On a recent CDCAN teleconference (See post dated 6/22) Julia Mullen, one my favorite people, presented the long-awaited as-yet unfinished waiver proposal for self-determination. My phone started ringing pretty quickly with brutally and predictably successful attempts to have my opinion on the topic. Self-direction is a tidal reform, as potentially important as the Lanterman Act was in it's time. So, the fact that it could arrive over the next few years as a viable alternative for many people with disabilities is: exciting, scary, encouraging, troublesome, hopeful, sinister, etc. Like all big change, really.

Also, there are a lot of issues- some conceptual and more that occur in the space between theory and practice. After the teleconference I decided that my next few posts on this site would be a series on some of the issues that I think are important related to self-determination, with maybe a one-off post next week on a Christmas-y theme.

First- the primer: Self-determination (self-direction ((SD)) refers to a system in which individuals or families served are given a budget to control. In the traditional system, Regional Center staff determine what the client needs and procure something similar regardless of cost under a host of regulations that define and limit and motivate and control available resources. The services are controlled, but the cost is not. Under an SD system, the cost is prescribed but the services are regulated primarily by the client. The person served has a great deal more real control over services including a larger share of the oversight, accountability and right to define what (or who) is a useful support.

Now, the introduction to the upcoming series:

The postings on self-direction will try to approach a lot of the issues around SD in general and the current contents of the waiver to be proposed. The goal will be partly to demystify what is being proposed, to clarify which parts of the future regulations I feel really need to be written right, and, in the name of full-disclosure, to advocate that our community seek to refine SD but not to block it. In the end, my biggest fear about the future of SD is that we will allow the perfect to be the enemy of the good.

First-thing to know: As Dr. Mullen described the upcoming regulations, California's SD program will be voluntary and accessible in both directions. The promise, and its an important one, is that everyone who fears SD, or is served badly by it, will be free to remain in or return to services under the current model. I do fear that the blackhearted gnomes who run many Regional Centers will use the SD option to tighten control over client's served under the traditional model, but generally as long as the system is truly optional in both directions, there is no erosion of clients' rights.

So: Here are the big issues around SD that I see as deserving the inquiry of our community. Subject to any feedback I may receive later- these will be the topics I'll cover in this series:

1. SD is reform, not "reform." Here are the differences between reform and "reform:" The former actually creates efficiency and lowers costs in parallel with lower funding in order to maintain or improve services. The latter is 99% more likely to occur and is bull-sign.
2. SD, if done correctly and honestly, will erode the importance and budgets of both regional centers and vendors (in the aggregate) in California's DD system. If it doesn't, it won't work.
3. SD will increase the opportunity for fiscal abuse of people with developmental disabilities. Expect to subtract from both the new freedoms and the new savings generated, costs and controls related to preventing. identifying and prosecuting abuse. The mandatory fiscal agent is a positive example of the costs and control above.
4. The savings threshold planned may be unrealistic for a while. The current plan calls for individuals in the SD program to have budgets which average out to 90% of the current cost of the program and to hire a fiscal manager (paid for from the 90% remaining) to share the oversight role. When I ran numbers looking for savings under the SD model, I came up with an initial 12% cost-reduction for services to be shared between the state's budget, the client's level of support and my own operations. One way the SD program might fail is if the benefits to the client and provider don't materialize. I would strongly encourage a phased-approach to savings.
5. Remember that the success of SD as a concept depends on a marketplace for services and supports that needs to develop and mature. I expect SD to succeed in the medium term but it may well seem a catastrophe six-months in.

Friday, December 03, 2004

Best practice?

As I have mentioned many times before now, California's system of services to people with developmental diagnoses seems to teeter between the highly individualized, market-based, community-centered system envisioned in the authorizing legislation and the bureaucratic, standardized one that naturally evolved in the state-funded environment. Doubly ironic, but also a singular opportunity to explore the future of social services.

One place near the joining of this system's two natures is the so-called "best-practice." Best Practice is a concept widespread in the helping professions. Those of us who work in those professions (technically, I'm an administrator and therefore no help to anyone, but still...) prefer our jargon to be inclusive, which is the opposite of defined. To the extent the phrase means anything (and the first word absolutely never does,) it means methods that someone thinks ought to be common. Best practices might be methods that seem to work, and/or are ideologically derived, got written down by someone, or at least seem methodical.

In the world of Regional Center-funded agencies, "Best Practices" usually means forms that you fill out to prove that you did or said or tried to do something that the regional center thinks should be done or said or tried with everyone. This makes best practices an interesting part of our system because they either represent an expansion of the accountability that the system runs so short of; or an intrusion of standardization into a system in which both quality and efficiency derive from an individual framework.

Over ¡Arriba!'s five-year focus on becoming more client-centered and, therefore, less standardized, indicators are that the clients have grown safer and more stable in their independent lives. Our caseload is too small for this to qualify as statistics, but we clearly have gotten better at prevention and intervention and response by eliminating our internal best practices. From that standpoint, I always meet the laudable goals of most "Best Practice" conversations by feeling the goals will be better served without a new standard.

On the other hand, I'm also convinced that accountability is sorely lacking in this system. I have argued strenuously on this page and elsewhere for an outcomes- or results-based system of accountability. The process-based system of accountability that barely exists is a sorry substitute and "Best Practices" clearly extend that. I suppose if you accept that this system isn't even getting ready to start to develop a useful system of accountability, then the "Best Practice" model makes enough sense to weigh against the protection of person-centered services.

What this entire argument does present, however, is that increasing standardization is the cost of failing to provide true accountability for the results provided. As long as we don't measure and track outcomes against ambitions, and publish the results we should expect the system to grow more standardized, less innovative, less efficient and less individualized.