The end is nigh, eat at Joe's

The $10 Billion deficit the State is facing is likely to deepen rather shallow and most of the tricks we've been using for the last five years are no longer available.  Cuts to the Department of Developmental Service's budget can be anticipated.  It may be a short period of anticipation, too, relieved by midyear changes to the budget, although expecting the legislature to move too slowly is not unreasonable.

Whatever the cuts will be, they won't be smart.  If we kept data on outcomes and the value added by programs and models to the lives of people with disabilities, the cuts could focus on the least helpful programs to preserve the most critical, helpful or useful.  Since the only outcome metrics currently employed are the self-righteousness of the providers, clients and families, all indications are that every program and agency appears crucial and excellent, I am pleased to report.

If there were reasonable transparency, we could anticipate that those agencies that provide the most cost-effective care might be favored for referrals and some of the deficits made up by suggestions that those people with choices to make be encouraged to consider the cost.  Since the referral process is not transparent, nor the evaluation process and the cost data is fairly meaningless, our only hope for absorbing cuts through information is the assumption that IPPs will be more thoroughly considered in the lean times.  The good news is they won't be less thoroughly considered by and large.

So, the cuts are fairly doomed to folly.  Another question, though, is will they save the state money?  That is questionable.  Lacking information on what works and what saves and what costs (a recent spreadsheet handed out at Assemblymember Buell's hearing in San Jose estimated savings to taxpayers from people with disabilities working but did not include estimates of taxpayer costs to find, create and support the jobs,) it is likely that this year's "cuts" will be of the normal sort, meaning services and supports that lower cost will be targetted equally with those that are relatively expensive and if rates are reduced it is likely to be by an even percentage, putting the low cost providers at disproportionate risk as compared to the high cost providers.  In the end, without drastic moves against the Lanterman Act and its entitlement itself, the system will probably suffer a deficiency that, by a second year, may be greater than "cuts" written into the budget.

There would be a better way if outcomes were measured and information made usefully available to people with disabilities, their families, regional centers and providers.  There would be a better way if there were a reliable means of accountability.  Instead, the legislative and executive branches will do their level best without any useful information.  My frustration will continue to be how little effort gets put into getting smarter.

For those of us who really want to see Self-Directed Services grow and prosper, though, there is a silver lining: The nags, scolds, sanctimonious pencil heads and vampires among us may accidentally wind up temporarily on the side of the angels.

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.