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 individualI 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.
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.