Monday, April 28, 2008

What's not in the DDS Report, Controlling Regional Center Costs, Part II

Another cost-saving, service improving fantasy of mine is the idea of outcome- rather than cost-based payments.  The idea is similar to Self-Directed Services but would be more appropriate for those clients less able to manage their own programs.  The idea is that specific outcomes can be priced based on the difficulty of reaching them and a general idea of the individual's special challenges.  This method can improve services and reduce costs to the extent that:

1) The objective is clearly defined and observable.  "Adolph will maintain optimum health" or "Joanna will be happy in his home" are not the quality of IPP goals that work best for this.
2) There is sufficient information, honestly (!) brokered on behaviors and other non-obvious challenges to be overcome.
3) Clients do not reach their own objectives currently because the system's incentives are geared toward maintaining the status quo or, worse, letting crises develop.
4) The cost-based approach is absurd and inefficient, except as compared to the rate structure it generates.

Granted this is so different from what we do now, that lots of input would probably improve the suggestion, but the basic idea is that the objectives would be priced and agencies willing to undertake the job could be interviewed by the client.  An agency that delivered success for clients in a timely fashion would be overpaid according to current standards, while an agency that was unable to accomplish the client's goals would not be paid at all.  

There is a danger that clients who are hard to work with, have more audacious goals, or present greater risk will be hard to find support for at any price, so the method might never safely replace the current model for everyone.

What do y'all think?

**UPDATE** The scary smart friend I referred to in the earlier post emailed me to look up 4648(a)7 in the Lanterman Act in reference to this post.  It reads:
(7) No service or support provided by any agency or individual
shall be continued unless the consumer or, where appropriate, his or
her parents, legal guardian, or conservator, or authorized
representative, including those appointed pursuant to subdivision (d)
of Section 4548 or subdivision (e) of Section 4705, is satisfied and
the regional center and the consumer or, when appropriate, the
person's parents or legal guardian or conservator agree that planned
services and supports have been provided, and reasonable progress
toward objectives have been made.
I think a lot of things about this line of code are interesting, both in light of this post and also in light of the requirements that no service can be discontinued without the agreement of the client or the opportunity to appeal. A tension between two statutory requirements, resolved through universal noncompliance.  But to the point at hand, I'd say that discontinuing services that produce no results is a good way of involving some little bit of natural selection into the process (in other words, a well-conceived ignored statute,) but you can improve on that by allowing agencies that achieve results more efficiently to capture some of the benefit of success.  This is likely the only way that excellent workers will ever be paid significantly better than indifferent personnel.


Andy said...

This topic was posted two days ago . . . somebody go check on Stanley!

Doug said...

Andy, I noticed that too. It's not like we're on topic there either.

stanley said...

chk on Stanley...OK make fun of an old gonna be old before you know it...

as will the children w/ special needs...they need cost-saving, service improving NOW. NOT the absurd and inefficient support provided...

[doug say] Another cost-saving, service improving fantasy of mine is the idea of outcome- rather than cost-based payments [...] The cost-based approach is absurd and inefficient, except as compared to the rate structure it generates. What do y'all think?

Well of course outcome based payment...there is no factual cost basis...cost are figments of bureaucratic bean counter imagination (actually lack of same) budgets...and decades of gaming the system to meet these budgets laced with deficit crisis, mindless, across the board, cuts and freezes.

specific outcomes can be priced...out of the box...perhaps price the IPP goals (establish a time sensitive cost to accomplish)...providers submit bids to accomplish...a lump sum contract concept...with of a time/material (rate) component for basic care.

Difficult to implement, yes. Impossible, no. would take accountable leadership...who would be responsible to one is now.

BTW were there any comments re What's not in the DDS Report made at recent MartyO Townhall mtg with DDS


Doug said...

Stanley, we can probably try outcome-based pricing without changes in statute. There was some small discussion of what's in the report, nothing on what was left out?

stanley said...

[doug say] we can probably try outcome-based pricing without changes in statute.

bet so...

in fact believe much, if not most, of changes and enforcement could be accomplished without statute,

"stay put" could be handled by DDS and CDE director directives...not to mention 2001 SDR recommendations...also probably much of the Blue Ribbon proposals...

ditto other report/studies that gather decades of bureaucratic dust...while new commissions are appointed to provide illusion of progress...



Doug said...

Nice bolding, Stan! What is "stay put?"

stanley said...

[doug say] What is "stay put?"

will be sorry you asked.

Disability advocates see AB 2717, along with AB 1768 by Assemblymember Noreen Evans dealing with special education due process hearings and the issue of *stay put* (see below for details), as critical bills that impact the special education fair hearing process and the rights of thousands of children with special needs and disabilities and their families. School districts and those opposing those measures have cited limited resources locally and statewide.

Requires local educational agencies, during the pendency of a hearing involving an application of a pupil for initial services under a preschool program serving individuals with exceptional needs who is no longer eligible for early intervention services because he or she has reached 3 years of age, to continue to provide of the same services that were provided under the Early Intervention Services Act.

* Would place the *burden of proof* in a special education due process hearing on the responsible educational agency, except with regard to the appropriateness of a unilateral parental placement or related services in a case where the parent or guardian is seeking tuition reimbursement for the placement or services.
*Specifies that *burden of proof* includes the burden of persuasion and the burden of production.

[Stanley say in DDRights Post]
[how can a link be added]

There is a DDS/CDE funding issues...NOT a needs issue
there are certain services provided by school districts and others provided or purchased by regional centers...special needs children/adults should not be denied services while DDS/CDE feuds over who purchases needs.

Assemblymember Evans has introduced a bill to fix the STAY PUT problem. It is a very good bill, creating a right for a child to stay in his or her PRESENT educational placement pending resolution of any dispute
The bill is currently the only item on the Assembly Education Committee agenda for March 5, so there is a chance to talk at considerably more length than usual to this vital group.

Caveat: none of the following is meant to minimize the importance of participation in the 5 Mar mtg...nor to deny there is a problem...butbutt;

it seems the root causes of the mess should be addressed as well...which seem to be:

1) special needs children not covered by Lanterman
2) families not aware of their rights.
3) early start programs not included in IPPs (why)

above based on:

[ref say] Advocates say the impact is critical for those children not eligible for regional center services under the Lanterman Act...and that for those children who are eligible, many families they say are not aware of what their rights are.

Perhaps efforts should be focused on eligibility requirements and insuring families are aware of their rights.

Point of information: if not why are early start programs not included in IPP...seems like another reason to have a uniform Early Start/IDEA/IPP/IDT cradle to grave TEAM...what say Blue Ribbon, SCDD, ABs, PAI...this was the intent of Lanterman.

Indeed: It is ironic that just as all the autism commissions have stressed the importance of continuity and early intervention, the actual course of regulation, law and of course enforcement have been going in the opposite direction


actually the laws that stress continuity are flat out broken...there should be no need to have to seek legal advice to get continuity guaranteed under Lanterman...IT SHOULD BE A GIVEN.

Andy said...

Doug---or anyone else not prone to bruising their shins on the conceptual---help me out here on the practical application of “outcome-based” services or payment.

(I’m the type who needs the Classic Comics version of “Waiting for Godot” or “Finnegan’s Wake,” and the like. Anything mildly abstract---themes, ideas, language---must be condensed and simplified . . . and, of course, I need the pictures . . . most of all, pictures!)

I can understand an outcome driven system applied to supported employment services (up to a point)---the outcomes being “a real job” or the training of new skills leading to promotion or a pay raise---but my grasp begins to slip when I think of other types of services, or outcomes in perpetuity; and if there’s one thing that defines our business, it’s perpetuity.

Staying with employment services for now, a young woman in a workshop decides she wants a job in the world and gets a goal stating, “In six months, Guinevere will work at Home Depot”. . . a clear, rational goal with a clear, achievable outcome. She gets the job . . . the orange apron, the name tag, the employee discount on a cornucopia of caulking . . . the world is her oyster . . . and then what? She lives with her dad, pays a little rent, and has no interest in moving out at this time. She is healthy, active, rides the bus, and sees her friends when she wants. Things are good. So what’s the next outcome?

Occasionally she needs a little ongoing job coaching. Perhaps she’s accidentally learned something about drain traps and has been heard providing customers with good, accurate advice and information on the options for clean-out or replacement and installation. She’ll need a job coach to retrain her on spotting confused customers---before they spot you---and adroitly disappearing into the foliage of the garden section. Or, if customer interaction is unavoidable (i.e. there is no more space in the trees among the assistant managers and other employees), Guinevere may need coaching to remember how to shake her head, pause and repeat, “Gee, I’m not really sure, this isn’t my section . . . there should be someone on aisle 84 who can help you.”

Job coaching after the intensive phase, reduced though continual, is usually a maintenance service . . .

(I am, at the moment, fighting a strong urge to go off on “job clubs” and other charades developed by agencies to bill their monthly 20 hours of ongoing and often unneeded support)

. . . [Doug say] “Adolph will maintain optimum health” or “Joanna will be happy in his home” are not the quality of IPP goals that work best for this (outcome-based payment).

Assuming I haven’t misunderstood this part of the proposal, how would services intended to maintain a good job, good living arrangement, or any stable situation satisfying to the individual, be compensated? How would you pay for driving someone to her neurologist, helping her correctly complete a form on her, and her family’s medical history, explaining the effects and side effects of a new medication, monitoring the effects, etc.? In short, how do you pay for a wide array of crucial services one may need to maintain optimum health?

If the system mandates that every service produce a succession of “specific, clearly defined and observable” outcomes, outcomes representing measurable change, or quantifiable improvements, or demonstrable differences, isn’t it also then demanding of its clients an endless sort of quest? Does a life in an outcome-based system become a personified manifest destiny of forward progression? Of unremitting change, unrelenting challenge and incessant self-improvement?

Would it stop at a certain age? When one could retire from the oppression of one’s goals . . . and simply chill?

I have a hundred and fifty more questions and a dozen concerns about whose preferences will pervade our “preferred” outcomes. I dread our old standbys . . . 100%integration . . . “real” friends (only the nondisabled need apply) . . . unpaid supports, et. al.

And, I need a lot more pictures.


Doug said...

Stanley, that sounds like a good idea. I'm not going to research further because I'd like to think there was one good piece of legislation in 2008.

Andy, here's how I think it works: Guinevere wants to work at Home Depot. Considering Guinevere's desire and the challenges she faces, a bounty of $5000 is placed on that, $4000 on a different competitive employment job and $1000 on volunteer positions that prepare her to work. Another $3000 is available if she maintains her employment for three months, after which, if she still needs support, her IPP can be changed to "Guinevere will maintain her job at Home Depot" with a $250/month bounty which can even be reduced if her Manager says "Sure she needs a little help now and then, but we'd hate to lose such a good worker. Too bad about the whole stalking her supervisor thing."

paul said...

"Another $3000 is available if she maintains her employment for three months" Doug

What if Guinevere decides after 2 months that she no longer wants to work at Home Depot? Does the provider lose the 3 grand even if Guinevere fails in the objective because of no fault of the provider?

If so - how will we deal with the conflict of interest between a providers goal to serve Guinevere and the sound business goal of getting the 3 grand at the end of the rainbow?

Doug said...

Paul, I think so. The paradigm change is that we no longer pay for effort but for value. The prices need to be set so that there success is rewarded sufficiently that the likelihood of external (to the provider) influences make the service sustainable while agencies prone to failure are driven out of business and agencies prone to failure are overpaid by today's standards.