Wednesday, April 18, 2007

Diamonds and dirt are forever.

If you want to level an accusation against regional center vendors generally and be confident you can make it stick, this vendor recommends "They suffer fools far too gladly." Westside Regional is in its, approximately, fourth attempt to convert Independent Living Services (currently service code 520, for those keeping score in your programs) into a standardized supported living-like program funded at a flat rate.

There are many astonishing aspects to this: the durability of demonstrated bad thinking, the ascendency of paperwork over people in the proposal, that the initial public conversation about each attempt always begins with a plan rather than a request for insight, the ivory-tower thinking of a community-based non-academic institution, the failure to account for client rights or the passive acceptance by vendors of a plan contrary to their own interests, hypothetical values and the needs of the people they serve. It's a little hard to pick out the worst aspect of this iteration and probably not worth the effort.

A little history, to be read as though it were in the oral tradition because I don't have time to fact check. Some time, in or around 2001, it was explained to me that Westside had conducted a pilot test of flat-rate ILS but that in the evaluation it was discovered that vendors did, in fact and strangely enough, respond to incentives and underserved their clients. Clearly, flat-rate ILS was an experiment that failed.

Nonetheless, the proposal returned from the grave twice more before now with the added twist of requiring the ILS vendors to become SLS vendors without changing their scope of service, except perhaps, to add 24-hour emergency response to replace the Regional Center's. On the first of these occasions, DDS was made aware by vendors of the proposal and a message was sent through vendors that the proposal did not appeal to the Department and could not be supported under the regulations. The second time, a letter was sent by DDS with the same message. Part of what makes this proposal so mystifying is that it seems to have no consituency beyond the Regional Center bureaucrats. If it were a tolerable cost-reduction scheme, DDS, at least should have liked it.

And here we are again. I was not present at the vendor meeting where the latest draft was announced, but as it was reported to me the Westside vendors offered no resistance. Maybe they see something I'm missing, but based on my reading of the proposal I can only imagine that either the vendors agreeing haven't thought the proposal through or they already know they'll cheat.

The plan calls for a minimum weekly activity with a flat rate covering that effort or more, plus a significant amount of paperwork beyond what is called for in regulations. On an hourly basis, the rate equates to $35.71 per hour, as a long term average, is higher than many ILS agencies receive but less than what others receive. However in long months, that rate will fall to $30 which, while higher than ¡Arriba!'s rate, is lower than most. There is no compensation for the extra paperwork and no allowance made for even small spikes in service, need or planning requirements (A medical appointment, court date or an SSI appeal can not be accomplished in increments of one hour.) If an agency provides even a small number of hours beyond the minimum, the effective rate is likely to fall 30% or more from their state-set rates. Furthermore, by requiring the activity to be weekly, the proposal would prohibit agencies from concentrating sparse hours to reduce the cost of paid travel between clients. This is why I am certain that agreeable vendors must either be fooled or frauds.

There are massive problems afflicting the proposal with regard to the rights of clients. To eliminate vendor code 520, and implement the new reporting requirements, the regional center would need to a) not inform clients of available alternatives, b) cancel services categorically, c) cancel existing services without ID team meetings and due process. All of these steps are necessary to implement this proposal and none of them compliant with existing statute, relevant regulations and/or federal law (in the case of Medicaid waiver clients.)

To summarize, this proposal has a long history of failure, is illegal, hypocritical, unhelpful and impractical.

And yet, there is value in this proposal: It is a perfect example of why innovation fails in this system. While there is no explicit goal for this proposal, beginning the conversation with a purpose and developing, in collaboration with vendors and clients, might have led to a solution with the possibility of a positive outcome. You can almost hear the voices within the regional center saying "we have to make our plan internally and then announce it as a done deal or else the vendors will just put up obstacles." By making that choice, they've left us with no alternative.

It may be worth noting that the Executive Director of this regional center delivered a scathing criticism of vendors for not providing attentive, responsive and individualized support at the New Day conference in 2005. Hopefully, the irony that he is overseeing a persistent effort to standardize the individualized services Westside can offer is amusing to someone.

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