Wednesday, December 30, 2009

Looking forward to 2010

Well, heck. The new year will bring new cuts. We all have known that for a while and none of us have any excuse for not being ready for them. I just updated my resumé, for example. I do hope people understand that the next round of cuts proposed might eliminate entire programs and, perhaps, state departments. But for my optimistic year's end post, I'd like to suggest criteria for guessing whether DDS thought through the cuts it is about to propose:

If the cuts proposed have been (tragic but) thoughtful:
  1. Rates will compress toward the low end, not fall by a fixed percentage.
  2. In explaining the cuts, resistance by large lobbying organizations won't be mentioned.
  3. Those will be least affected who are most urgently in need.
  4. The package will contain not only clear descriptions of what regional centers are to do differently, but enforcement mechanisms for reining in inventive interpretations or, at least, an expressed and manifest willingness to publicly side with other stakeholders some of the time.
  5. Andy Pereira will need to think a short while before ranting.
  6. Some non-residential agencies may actually close.
  7. Contrary to the "furthest from the client" meme, the scope of support will narrow more than oversight fades.
  8. Many members of the cost-cutting stakeholder group will complain that they weren't listened to and mean it this time.
  9. The interdisciplinary team (IDT) approach, Individual Program Plan (IPP) primacy and fair hearing rights will be strengthened.
  10. The limits on the IDT and IPP will be clarified, in terms of requiring a clinical and practical rationale for support.
To expand on my thinking (apart from my comment about Andy- you just gotta know Andy,) ideology will not produce a budget solution nor a human solution. To get both, consideration must be applied to efficiently shrinking the system, maximizing cuts realized (rather than scored) and minimizing disruption acknowledged (rather than ignored.)

The first challenge is that we have spent years in denial that any change to the system is necessary and one result of that is that the map of the system isn't much more detailed than it was 9 years ago when I got here (and when the map showed "Here be dragons" across the state.) So there is no real possibility that the changes to be proposed will be wise or wholesome.

That said, some common sense can be applied. It is clearly better to retain a decreased number of low-cost support agents than to continue trying to keep all the state's executive directors employed. This is why a downward compression of rates is wiser than a fixed reduction and why it is better to restore the clinical and practical requirements to the scope of a client's service than to list categories of service to be discontinued.

Because we can't describe our current reality (without lying, exaggerating or generalizing beyond the scope of surrealism,) it is important to retain whatever intelligence the system does feature. This is why both quality assurance and the ID teams remain an important feature. There's also some hope to be had that if the system shrinks more than its smarter features, the system itself can grow a little less mystical in process and product.

Likewise, for the system to grow smarter it is absolutely mandatory that regional centers grow less glib, for clients to have clear understanding of new limitations and for some agencies to close. But the most important factor is that stewardship of this system and its resources for the benefit of the people served has to improve for the remnants to matter. Which is why such proposals as an x% rate cut across the board or the evacuation of regional centers will prove a lack of good thinking by the administration.

Of course, this budget is bad enough that we just have all non-residential care proposed for elimination. In which case, dangit.

9 comments:

paul said...

“Which is why such proposals as an x% rate cut across the board or the evacuation of regional centers will prove a lack of good thinking by the administration.”
Doug

Doug,

What is the likely alternative to “across the board” cuts? When I say “likely” I mean in the real world of Sacramento.

That is – if we do not have across the board cuts is the likely alternative “good thinking” by the administration and cuts that reflect that good thinking?

Will the alternative decision process, which will be needed in lieu of across the board cuts, be more equitable or will the end result (cuts) be more reflective of the power of each lobbyist and/or stakeholder group?

Is it possible, if not counter-intuitive, that because of the nature of politics that across the board cuts can potentially be the most equitable cuts?

Doug said...

Paul, the real world really ought to have changed by now. There's nothing unrealistic about, for example, capping rates at the temporary rate level except that DDS doesn't know how often rates higher than that are paid so they can't score the change.

I think the more artful you make things the more likely the shenanigans, so I understand the need for a simple standard which in my case is some new cap on rates and in DDS' last proposal was a 3% cut. I think the difference is not one of equity but practicality. There's no reliable evidence that agencies with higher rates are more helpful (although this may be so) so by targeting higher rates, you reduce the risk that rates actually paid rise up because the low-cost agencies close.

I should disclose that the agency I work at (at least until the cuts are implemented) has a rate around 15% below the temporary rate. I hope I've said enough in the past that, implemented, would have made my life harder to get credit that I'm not spinning this just because it's better for me.

Andrew said...

I will need to think "a short while" before ranting?

I know this doesn't speak well of my rants, but all I do is think! Every day for the last 30 years ... "think, think, think," as Pooh would say while jabbing his forefinger into his forehead.

As Doug pointed out,(precluding any need for me to think) his agency (we'll call it A-Rebar) is operating at 15% below the temporary rate. If they're doing anything decent they should not have to bear the brunt of across the board cuts ... and brunt it would be ... as I hope it's pretty obvious by now that poorly paid providers certainly suffer more than our well-funded cousins, when someone mumbles "fairness" and affixes blindfolds on the firing squad and shouts, "Ready ... Aim .... Across the Board!".

I started to diversify our services a few years ago in anticipation of "dark days a'comin'", and our growing ILS services are now propping up our supported living services. It will hurt supported living, for us, when ILS gets cut. If our supported living could stand on its own, I wouldn't have a problem with 10% to 15% cuts to our ILS ... and I would support such cuts to us, before seeing lesser cuts to A-Rebar.

There is a hell of a lot of money in this system. Where it goes is the true problem. I think I mentioned before that for us to earn $1000 in our standard supported living, we must provide nearly 60 hours of support (and that includes our stinking admin rate! ... for all you administrative rate apologists!)

For a sheltered workshop operating with a temporary rate, $1000 is earned after only 11 hours of service (at a 15:1 ratio). I know they've got some overhead and operational costs that we don't .... but c'mon .... the equivalent of 39 hours of overhead for every 11 of support? And some of our operational costs, such as comp and liability insurances, increase with the more hours of service provided ... such is the brutal truth of actuaries.

In any case, this is not meant to muck up the discussion (I don't want to step on Paul's toes). I'm simply adding my two cents (Of course, if I ran a workshop, I could add a lot more than that ... and still have a plenty left for round of steak dinners following an aperitif or two of absinthe).

By the way Paul, for someone who sells White Zin to lonely housewives, you certainly seem to not give a second thought to casting such aspersions onto others ... do you, Mr. Jones?

Andy (one who shall go forth and zin no more)

paul said...

"I don't want to step on Paul's toes"

I enjoy this blog because it refreshingly does not need the usual disclosures, preambles, and qualifications.

But just in case - I BELIEVE THAT ACROSS THE BOARD CUTS ARE UNWISE AS WELL.

paul said...

"...for someone who sells White Zin to lonely housewives, you certainly seem to not give a second thought to casting such aspersions onto others ... do you, Mr. Jones?"

??The Graduate??
Sorry it has been a while, and we do not have a TV in the Workshop - all work no play.

Doug said...

Andy, I think that's it (the blindfolded firing squad.) At this point, the damage is severe enough that fairness towards vendors generally ought to be out of the formula.

Paul, good to have you on record. All I remember about The Graduate is "plastics" and Anne Bancroft in shadow but that sounds like Ballad of A Thin Man to me. Well, just the last sentence but still.

paul said...

“Paul, the real world really ought to have changed by now. There's nothing unrealistic about…”
Doug

I agree, “the real world really ought to have changed by now”,

The fact that the real world is what it is and isn't as it “ought to be” seems to me to indicate a discussion that is needed, but never happens. Hume's guillotine comes to mind as well

"There's nothing unrealistic about"
Doug

There is nothing unrealistic about me climbing K2, but I tell ya what – IT AINT GONG TO HAPPEN.

I think Andy probably supplied support for a point:

“c'mon .... the equivalent of 39 hours of overhead for every 11 of support?”

That is – there seems to be an absence of logic and fairness within the system of distribution, which is predominately at the Regional Center and provider level. If this is the reality then it means that we cannot safely presume that across the board cuts are more harmful to an individual provider or consumer basis as compared to more “intelligent” cuts.

Put another way – If cuts are made more “artfully” there is no reason to believe that Andy and Doug inc. will get less than a 3% reduction while Sheltered Workshop R US will get more of a reduction.

IF the above is true then we are again missing a more important discussion.

Furthermore – that are indications that surgical reductions may be susceptible to legal challenges.

Another discussion...

Can we discuss a road trip to Hawaii without mention of the Pacific Ocean?

stanley said...

[doug say] Looking forward to 2010...Well, heck...If the cuts proposed have been (tragic but) thoughtful

Too many qualifiers...weel only one: thoughtful

anyhow, discussing one criteria for guessing whether cuts though through thoughtful: The interdisciplinary team (IDT) approach, Individual Program Plan (IPP) primacy and fair hearing rights will be strengthened.

Actually if this were done the other nine criteria (even, Andy Pereira will need to think a short while before ranting) would automatically be there...so much for the discussion.

buttbut thanks for the thoughtful consideration of the state of DDS cuts

stanley seigler

Doug said...

Paul, I wish I had answered your comment before I put up the new post. I could have gone with Hume as a philosopher I've never read.

Stanley, I agree. The ID team seems to be flagging in reliability and growing in importance.