A few weeks ago, I was at a meeting with, among others, a woman (G) whose son (T), in his late teens with severe disabilities and superb gifts, was seeking assistance of the type our system was always intended to provide. G and T wanted support which would follow the choices T makes and the goals he seeks to attain. They wanted humble agency(ies) to provide individualized services. When Assemblman Frank D. Lanterman proposed the radical legislation that created California's community-based system as an alternative to institutionalization he specifically envisioned a system that answer this call. In the 35 years since Governor Reagan signed the Lanterman Developmental Disability Act, every advocate calling for support to our system or opposed changes to it have argued that Californians with developmental disabilities are owed exactly what G and T have asked for.
And yet, as of meeting G, she had been unable to find what is so clearly promised to her son. It's a disappointing moment that calls a lot into question.
How can we, every time a reform is proposed that we don't like argue the moral necessity of providing individualized, client-centered services if people who want them can't find them?
How will we demand the State pay the full cost of a community-based system when the $3 billion dollars already provided by the State and Federal Governments seem to be buying something else?
What does California's Community-Based system of support actually provide and why isn't it what its supposed to be? Can we get there from here?
To discuss the last question, I'm confident that we can get there from here. I think the system is readier to meet clients where they are and follow them than the number of conferences on bridging the gap gives it credit for. Most service providers and staff and many Regional Center personnel know how to listen and be humble and try things they don't know how to do. There isn't much else I would see in terms of needed capacity.
There must be barriers, though. When I met G, all she and T were looking for was basically to see the Lanterman Act enacted. And yet, G and her advisors were having trouble finding a ready provider. Wanna know what I think the barriers are?
I think the system designed as an alternative to institutionalization retains relics of exactly that system. The whole system of accountability is designed to work best when the Regional Center is in charge of the provider who's in charge of the client. We can talk all we want about clients owning their services, but as long as regional centers can punish providers for the natural consequences of client's informed choices (or the preferences of the family,) providers who serve humbly are resisting not following the natural design of the system.
There are other relics. What many in the system call the "big three" when they talk about services- i.e, residential group-home, day program and transportation is probably the most common service configuration. Why is it so common? It's probably the cheapest price-point for providing 24-hour care. It's also, essentially an institution without walls. It matters that there are no walls, but it is interesting that the community-based system so often emulates the experience of the institution.
The true, often hidden, brilliance of the community-based system was that it would allow individuals with disabilities to select their own preferred balance of risk and reward. If any law or public administration interns are reading this, a great project would be to review Titles XVII and XXII of California's Welfare and Institutions code to determine what percentage of the regulations bias DDS, Regional Centers, Providers and Clients against higher-risk solutions.
Monday, October 11, 2004
Friday, October 08, 2004
Three great values that sometimes go great together
During the ILS Coalition conference, a consultant to the state legislature talked about the conflict between emphasizing choice and emphasizing safety. It's a real comfort to see someone get this and I wanted to write a little about the values in our system and how they interact.
I think there are three main moral values written into state law regarding support for people with developmental disabilities. These three values are unanimously supported (at least in public but I think with general sincerity as well) throughout our community. These are:
1. People with developmental disabilities should live lives and pursue goals of their own choosing,
2. People with developmental disabilities should be as safe, as healthy and as well as possible, and
3. People with developmental disabilities should be integrated into the community as substantially as every other member.
These three values sometimes align with one another perfectly. Other times, these two or more of these values conflict or compete. A cliche we use is "People should be free to choose, but you don't let them jump in front of a moving bus." The problem with the metaphor is that it's a metaphor. What is the threshold for free to choose. When is someone jumping in front of a bus (other than when they're jumping in front of a bus.) I know people who work in this field who think eating poorly calls for aggressive intervention. Do you or do you not help someone with a seizure disorder join a hang-gliding club?
Integration is often even trickier. During an intake I once suggested to a new, young client that we could help her join a church choir because she was religious, isolated and liked music. Her answer, and I've heard it more than this once was "No. I don't like normal people, they're mean to me." This is a real conflict. Those of us who care acutely for people with disabilities want to live in a society where cerebral palsy, cognitive challenges, and other disabilities are traits not stigmas, like green eyes or a really bizaare sense of humor. Still, we can't promise people with disabilities that if they participate in the greater community that they won't be insulted, victimized or alientated. If we're honest, we can almost promise that they will be. We no longer question people with other minority identities who prefer the company of those they feel most like.
When we talk about these conflicts, someone always suggests a solution (a church choir where the music director has a child with disabilities.) I believe the solution is besides the point. In working with challenged people we've chosen conflict. The separate character of our system's participants is largely defined by balancing conflicts among our values. Some programs are, when the conflicts grow acute, highly risk-averse others are ultimately zealous about client choice while some purr about integration. The presence of different solutions to the same challenge among available supports is part of the genius of this system and as long as people with disabilities can find support that reflects there own values, our system works.
I think there are three main moral values written into state law regarding support for people with developmental disabilities. These three values are unanimously supported (at least in public but I think with general sincerity as well) throughout our community. These are:
1. People with developmental disabilities should live lives and pursue goals of their own choosing,
2. People with developmental disabilities should be as safe, as healthy and as well as possible, and
3. People with developmental disabilities should be integrated into the community as substantially as every other member.
These three values sometimes align with one another perfectly. Other times, these two or more of these values conflict or compete. A cliche we use is "People should be free to choose, but you don't let them jump in front of a moving bus." The problem with the metaphor is that it's a metaphor. What is the threshold for free to choose. When is someone jumping in front of a bus (other than when they're jumping in front of a bus.) I know people who work in this field who think eating poorly calls for aggressive intervention. Do you or do you not help someone with a seizure disorder join a hang-gliding club?
Integration is often even trickier. During an intake I once suggested to a new, young client that we could help her join a church choir because she was religious, isolated and liked music. Her answer, and I've heard it more than this once was "No. I don't like normal people, they're mean to me." This is a real conflict. Those of us who care acutely for people with disabilities want to live in a society where cerebral palsy, cognitive challenges, and other disabilities are traits not stigmas, like green eyes or a really bizaare sense of humor. Still, we can't promise people with disabilities that if they participate in the greater community that they won't be insulted, victimized or alientated. If we're honest, we can almost promise that they will be. We no longer question people with other minority identities who prefer the company of those they feel most like.
When we talk about these conflicts, someone always suggests a solution (a church choir where the music director has a child with disabilities.) I believe the solution is besides the point. In working with challenged people we've chosen conflict. The separate character of our system's participants is largely defined by balancing conflicts among our values. Some programs are, when the conflicts grow acute, highly risk-averse others are ultimately zealous about client choice while some purr about integration. The presence of different solutions to the same challenge among available supports is part of the genius of this system and as long as people with disabilities can find support that reflects there own values, our system works.
Monday, October 04, 2004
Evaluation, yet again
The ILS Coalition conference was last week, and it kind of got me going, so there may be a few posts this week. I promised earlier to talk in more depth about evaluation for system and the topic came up at the conference. Folks have waited avidly and long enough for the answers. Hating to disappoint anyone, here they are.
I guess the first question is why we need an evaluation. Here are three reasons:
1. To improve the quality of the system,
2. To eliminate waste in the system,
3. To learn how policy decisions are connected to outcomes.
California's statutes which set out the goals and methods of the system set some criteria for how quality is defined. The system succeeds when it:
A. Provides support for the choices clients make as to how they live and which goals they pursue,
B. Allows people with developmental disabilities to live lives similar to those experienced by their non-disabled peers (this is typically, but not necessarily described as integration of clients into the broader community),
C. Preserves the health and maximize the safety of clients.
Since evaluation becomes the set of incentives that professional participants face, the system that works for California should respond to the needs numbered 1-3, while incenting the mission of the system described in A-C. To accomplish all of this, the following should be elements of a statewide system for evaluation:
Client-centeredness: While the evaluation has to begin with valid outcomes which will make sense in the aggregate, the value of the measurement should depend on the stated goals of the individual client. Some of the waste in our system comes from supporting individuals to accomplish goals that don't interest the client. Sure, I agree, everyone should work and participate in the greater community but its awfully easy to lose an unwanted job or get kicked out of a club you hate to see. The statewide evaluations can and should aggregate the outcomes the clients choose to pursue rather than measure the success of clients in achieving statewide policy goals. I bet I write a better explanation of this another day.
Reasonable Expectations: A baseline level of accomplishment should be predicted and the outcomes judged against that baseline. This doesn't suggest low expectations, it refers to the idea that clients who face greater challenges should be as desirable to serve as people who are more typical of the population at large. No-one can defend planning for people based on traits like measured IQ, assessed functional abilities or behavioral history. Nonetheless to extend proper credit and reward audacity, baseline expectations can and should be adjusted with standard measures of ability. This can not only help make more challenged clients more attractive to serve, but may ultimately allow clients and their family members to identify agencies that may succeed especially well (or fail spectacularly often) with similar challenges to theirs.
Universality: Evaluations should focus on every client every year and reflect on every program they used and the regional center they're with. In order to identify successful strategies, every program should be measured for success and diverse cohorts should be identified. With 200,000 participants an annual survey of client outcomes can quickly separate what is working with whom from what is waste. Furthermore, the potenial exists to make service and agency selection an informed choice which it isn't today. The faster successful programs and strategies are identified and connected to real people, the less waste and failed agencies will tie up scarce resources.
Transparency and availability: The means of assessing success and the scores achieved by agency, program type and regional center need to be accessible to everyone. This is where there's a pragmatic difference between California's private sector system and other states' self-run systems. In a single system, the goal of evaluation is to measure the success of the overall system. California's system depends on the private sector to provide and clients to select the services and supports which will succeed for each individual. The best system for eliminating waste would be to insure that people considering services have the means to identify the right supports and providers through clear, transparent and easily available information.
If you've read this far, I probably owe you lunch.
I guess the first question is why we need an evaluation. Here are three reasons:
1. To improve the quality of the system,
2. To eliminate waste in the system,
3. To learn how policy decisions are connected to outcomes.
California's statutes which set out the goals and methods of the system set some criteria for how quality is defined. The system succeeds when it:
A. Provides support for the choices clients make as to how they live and which goals they pursue,
B. Allows people with developmental disabilities to live lives similar to those experienced by their non-disabled peers (this is typically, but not necessarily described as integration of clients into the broader community),
C. Preserves the health and maximize the safety of clients.
Since evaluation becomes the set of incentives that professional participants face, the system that works for California should respond to the needs numbered 1-3, while incenting the mission of the system described in A-C. To accomplish all of this, the following should be elements of a statewide system for evaluation:
Client-centeredness: While the evaluation has to begin with valid outcomes which will make sense in the aggregate, the value of the measurement should depend on the stated goals of the individual client. Some of the waste in our system comes from supporting individuals to accomplish goals that don't interest the client. Sure, I agree, everyone should work and participate in the greater community but its awfully easy to lose an unwanted job or get kicked out of a club you hate to see. The statewide evaluations can and should aggregate the outcomes the clients choose to pursue rather than measure the success of clients in achieving statewide policy goals. I bet I write a better explanation of this another day.
Reasonable Expectations: A baseline level of accomplishment should be predicted and the outcomes judged against that baseline. This doesn't suggest low expectations, it refers to the idea that clients who face greater challenges should be as desirable to serve as people who are more typical of the population at large. No-one can defend planning for people based on traits like measured IQ, assessed functional abilities or behavioral history. Nonetheless to extend proper credit and reward audacity, baseline expectations can and should be adjusted with standard measures of ability. This can not only help make more challenged clients more attractive to serve, but may ultimately allow clients and their family members to identify agencies that may succeed especially well (or fail spectacularly often) with similar challenges to theirs.
Universality: Evaluations should focus on every client every year and reflect on every program they used and the regional center they're with. In order to identify successful strategies, every program should be measured for success and diverse cohorts should be identified. With 200,000 participants an annual survey of client outcomes can quickly separate what is working with whom from what is waste. Furthermore, the potenial exists to make service and agency selection an informed choice which it isn't today. The faster successful programs and strategies are identified and connected to real people, the less waste and failed agencies will tie up scarce resources.
Transparency and availability: The means of assessing success and the scores achieved by agency, program type and regional center need to be accessible to everyone. This is where there's a pragmatic difference between California's private sector system and other states' self-run systems. In a single system, the goal of evaluation is to measure the success of the overall system. California's system depends on the private sector to provide and clients to select the services and supports which will succeed for each individual. The best system for eliminating waste would be to insure that people considering services have the means to identify the right supports and providers through clear, transparent and easily available information.
If you've read this far, I probably owe you lunch.
Yet more on evaluation
The ILS Coalition conference was last week, and it kind of got me going, so there may be a few posts this week. I promised earlier to talk in more depth about evaluation for system and the topic came up at the conference. Folks have waited avidly and long enough for the answers. Hating to disappoint anyone, here they are.
I guess the first question is why we need an evaluation. Here are three reasons:
1. To improve the quality of the system,
2. To eliminate waste in the system,
3. To learn how policy decisions are connected to outcomes.
California's statutes which set out the goals and methods of the system set some criteria for how quality is defined. The system succeeds when it:
A. Provides support for the choices clients make as to how they live and which goals they pursue,
B. Allows people with developmental disabilities to live lives similar to those experienced by their non-disabled peers (this is typically, but not necessarily described as integration of clients into the broader community),
C. Preserves the health and maximize the safety of clients.
Since evaluation becomes the set of incentives that professional participants face, the system that works for California should respond to the needs numbered 1-3, while incenting the mission of the system described in A-C. To accomplish all of this, the following should be elements of a statewide system for evaluation:
Client-centeredness: While the evaluation has to begin with valid outcomes which will make sense in the aggregate, the value of the measurement should depend on the stated goals of the individual client. Some of the waste in our system comes from supporting individuals to accomplish goals that don't interest the client. Sure, I agree, everyone should work and participate in the greater community but its awfully easy to lose an unwanted job or get kicked out of a club you hate to see. The statewide evaluations can and should aggregate the outcomes the clients choose to pursue rather than measure the success of clients in achieving statewide policy goals. I bet I write a better explanation of this another day.
Reasonable Expectations: A baseline level of accomplishment should be predicted and the outcomes judged against that baseline. This doesn't suggest low expectations, it refers to the idea that clients who face greater challenges should be as desirable to serve as people who are more typical of the population at large. No-one can defend planning for people based on traits like measured IQ, assessed functional abilities or behavioral history. Nonetheless to extend proper credit and reward audacity, baseline expectations can and should be adjusted with standard measures of ability. This can not only help make more challenged clients more attractive to serve, but may ultimately allow clients and their family members to identify agencies that may succeed especially well (or fail spectacularly often) with similar challenges to theirs.
Universality: Evaluations should focus on every client every year and reflect on every program they used and the regional center they're with. In order to identify successful strategies, every program should be measured for success and diverse cohorts should be identified. With 200,000 participants an annual survey of client outcomes can quickly separate what is working with whom from what is waste. Furthermore, the potenial exists to make service and agency selection an informed choice which it isn't today. The faster successful programs and strategies are identified and connected to real people, the less waste and failed agencies will tie up scarce resources.
Transparency and availability: The means of assessing success and the scores achieved by agency, program type and regional center need to be accessible to everyone. This is where there's a pragmatic difference between California's private sector system and other states' self-run systems. In a single system, the goal of evaluation is to measure the success of the overall system. California's system depends on the private sector to provide and clients to select the services and supports which will succeed for each individual. The best system for eliminating waste would be to insure that people considering services have the means to identify the right supports and providers through clear, transparent and easily available information.
OK. That was probably arcane and boring even for this weblog. If you've read this far, I probably owe you lunch.
I guess the first question is why we need an evaluation. Here are three reasons:
1. To improve the quality of the system,
2. To eliminate waste in the system,
3. To learn how policy decisions are connected to outcomes.
California's statutes which set out the goals and methods of the system set some criteria for how quality is defined. The system succeeds when it:
A. Provides support for the choices clients make as to how they live and which goals they pursue,
B. Allows people with developmental disabilities to live lives similar to those experienced by their non-disabled peers (this is typically, but not necessarily described as integration of clients into the broader community),
C. Preserves the health and maximize the safety of clients.
Since evaluation becomes the set of incentives that professional participants face, the system that works for California should respond to the needs numbered 1-3, while incenting the mission of the system described in A-C. To accomplish all of this, the following should be elements of a statewide system for evaluation:
Client-centeredness: While the evaluation has to begin with valid outcomes which will make sense in the aggregate, the value of the measurement should depend on the stated goals of the individual client. Some of the waste in our system comes from supporting individuals to accomplish goals that don't interest the client. Sure, I agree, everyone should work and participate in the greater community but its awfully easy to lose an unwanted job or get kicked out of a club you hate to see. The statewide evaluations can and should aggregate the outcomes the clients choose to pursue rather than measure the success of clients in achieving statewide policy goals. I bet I write a better explanation of this another day.
Reasonable Expectations: A baseline level of accomplishment should be predicted and the outcomes judged against that baseline. This doesn't suggest low expectations, it refers to the idea that clients who face greater challenges should be as desirable to serve as people who are more typical of the population at large. No-one can defend planning for people based on traits like measured IQ, assessed functional abilities or behavioral history. Nonetheless to extend proper credit and reward audacity, baseline expectations can and should be adjusted with standard measures of ability. This can not only help make more challenged clients more attractive to serve, but may ultimately allow clients and their family members to identify agencies that may succeed especially well (or fail spectacularly often) with similar challenges to theirs.
Universality: Evaluations should focus on every client every year and reflect on every program they used and the regional center they're with. In order to identify successful strategies, every program should be measured for success and diverse cohorts should be identified. With 200,000 participants an annual survey of client outcomes can quickly separate what is working with whom from what is waste. Furthermore, the potenial exists to make service and agency selection an informed choice which it isn't today. The faster successful programs and strategies are identified and connected to real people, the less waste and failed agencies will tie up scarce resources.
Transparency and availability: The means of assessing success and the scores achieved by agency, program type and regional center need to be accessible to everyone. This is where there's a pragmatic difference between California's private sector system and other states' self-run systems. In a single system, the goal of evaluation is to measure the success of the overall system. California's system depends on the private sector to provide and clients to select the services and supports which will succeed for each individual. The best system for eliminating waste would be to insure that people considering services have the means to identify the right supports and providers through clear, transparent and easily available information.
OK. That was probably arcane and boring even for this weblog. If you've read this far, I probably owe you lunch.
Tuesday, September 28, 2004
John O'Brien and the right system design
This post is a week or more late. I received word from my good friend, Julia Mullen, that John O'Brien had recently undergone surgery, and that we all should be thinking of him. I've had a couple of articles he wrote that I wanted to discuss in this space but couldn't find them. After a week of hunting, and this being a weblog (no accountability or expectation of accuracy,) I'm going to write about his work without it in front of me, confident that I won't mislead very many people.
John and his wife, Connie are two of the most important thinkers who analyze, describe and advocate on how society treats people with disabilities and how society can do better. The solutions they describe are both common-sense and radical. Maybe the greatest lesson I've learned from them is the recognition that common-sense is a radical departure in human services. That's how far we have to go.
The article I wanted to write about but can't find talks about redesigning the system so the incentives are aligned with the goals (duh?) All participants are described as agents and are expected to pursue their own self-interest (duh?) It's common sense because that is how the world works everywhere. It's radical, because we design our human service systems on the assumption that people who work for pay should otherwise be altruistic, mortifying their own needs in order to pursue the best interests of those who need help. The belief that direct care workers, boards of directors, executive managers of agencies, regional center staff, etc. should forsake their own interests in order to serve the client is pervasive. But is it realistic or even constructive?
It passes the What Would Jesus Do test, but until He returns, one of the chief sources of inefficiency in our system is how much those of us who participate in it hide what we're really up to. I wonder sometimes how much the state pays annually for camouflage. We create forms and pay people to fill them out which help us appear to follow instructions we all find absurd. We go to meetings with quality assurance folks and they ask us to do things we're too smart to do and then train staff how to imitate bad ideas while doing well. I'll be shocked if, upon arriving in heaven I find out that the State of California and philanthropists spent less than $25 million this year in the developmental disability system to pay the cost of misdirection. I won't be shocked if it's $250M. Then there's the cost involved when people actually take bad suggestions and implement them. There's human cost to that as well.
Our lack of honesty is a lack of efficiency and a deprivation of the aspirations of those we serve. Clients do it, their families too, providers and regional centers and the administration. All of this, in large measure, to appear as though we are pure servants and not self-interested people doing the best we can for ourselves while doing our best for the people we serve.
It's cathartic to admit that I'm fat but still hungry, successful but still ambitious and my hopes for myself drive my work along with those of the clients I serve. Now imagine how much better our system would work if you could eat, buy and aspire more by helping more.
One of John O'Brien's important contributions to our system has been to describe how our system might work better if it were set up to harness the skills and good will of well-intended, self-interested people instead of relying on ascetics.
So, best wishes, Dr. O'Brien, on a full and speedy recovery. Our thoughts and prayers are for your lasting health. Not just for your sake but also for ours.
John and his wife, Connie are two of the most important thinkers who analyze, describe and advocate on how society treats people with disabilities and how society can do better. The solutions they describe are both common-sense and radical. Maybe the greatest lesson I've learned from them is the recognition that common-sense is a radical departure in human services. That's how far we have to go.
The article I wanted to write about but can't find talks about redesigning the system so the incentives are aligned with the goals (duh?) All participants are described as agents and are expected to pursue their own self-interest (duh?) It's common sense because that is how the world works everywhere. It's radical, because we design our human service systems on the assumption that people who work for pay should otherwise be altruistic, mortifying their own needs in order to pursue the best interests of those who need help. The belief that direct care workers, boards of directors, executive managers of agencies, regional center staff, etc. should forsake their own interests in order to serve the client is pervasive. But is it realistic or even constructive?
It passes the What Would Jesus Do test, but until He returns, one of the chief sources of inefficiency in our system is how much those of us who participate in it hide what we're really up to. I wonder sometimes how much the state pays annually for camouflage. We create forms and pay people to fill them out which help us appear to follow instructions we all find absurd. We go to meetings with quality assurance folks and they ask us to do things we're too smart to do and then train staff how to imitate bad ideas while doing well. I'll be shocked if, upon arriving in heaven I find out that the State of California and philanthropists spent less than $25 million this year in the developmental disability system to pay the cost of misdirection. I won't be shocked if it's $250M. Then there's the cost involved when people actually take bad suggestions and implement them. There's human cost to that as well.
Our lack of honesty is a lack of efficiency and a deprivation of the aspirations of those we serve. Clients do it, their families too, providers and regional centers and the administration. All of this, in large measure, to appear as though we are pure servants and not self-interested people doing the best we can for ourselves while doing our best for the people we serve.
It's cathartic to admit that I'm fat but still hungry, successful but still ambitious and my hopes for myself drive my work along with those of the clients I serve. Now imagine how much better our system would work if you could eat, buy and aspire more by helping more.
One of John O'Brien's important contributions to our system has been to describe how our system might work better if it were set up to harness the skills and good will of well-intended, self-interested people instead of relying on ascetics.
So, best wishes, Dr. O'Brien, on a full and speedy recovery. Our thoughts and prayers are for your lasting health. Not just for your sake but also for ours.
Monday, September 13, 2004
Rate reform
Aha! The third rail! Hold on, my zipper's stuck.
Rate reform means different things to different people but the following applies as a rule.
For vendors: Rate reform = getting more money for doing the same work for the same people.
For government folks: Rate reform = getting more of the same work for the same people for the same money. Quality is subjective anyhow.
I'm indifferent as to whether rate reform should raise the number of dollars coming into this system. I'm zealous, however that the irrelevance of support needed to funding provided needs to change. The failure is nearly total to correlate funding with the resources required to provide the right support, in the right amount, with sufficient quality to produce the outcomes that our clients seek and the State benefits from.
So, here's another primer. This time on how rates are currently set in this system.
There are really three methods of rate-setting. These are state-set rates, residential rates and negotiated rates.
In the most common (state-set) method as I understand it, a new agency receives a temporary rate which is the same for a given category of service regardless of where you are in the State (Inyokern rate=San Francisco rate.) The agency then functions for one year under that rate, fills out a statement explaining that agency's costs over that year and a new rate is assigned. Obviously, if you get the joke, in your first year as a program you spend every cent you're paid and lose as much money as you can afford to on whatever you can in order to produce as high a bill as possible at the end of your first year. The adjusted permanent rate circles over the agency forever, cawing to the great white whale that lurks in the deep. Once in a long while, the state adjusts the oldest rates and those older agencies go from the lowest rates to the highest.
So here's how various factors affect state-set rates, a few years after assignment:
Market value of qualified workers in an area: Irrelevant
Changes in worker's compensation insurance cost: Irrelevant
Cost of appropriate training and skill-building: Irrelevant
Administrative cost of regulatory compliance: Irrelevant
Quality of care provided: Irrelevant
Year Established: High correlation.
In negotiated rates, the agency predicts it's costs, tells the Regional Center what those will be, and then a process takes place leading to a contract to provide services at a given rate. According to the Legislative Analyst's Office, these rates increase at three times the rate of the state-set ones.
Residential rates, as I understand them (and I don't know that I do) works like the state-set rates but with a cost-of-living increase (suspended for several years now) so the correlation between real factors and rates would be like state-set with year of establishment being less relevant.
So the main factors in the level of funding that agencies receive for providing services are:
Whether they have been vendorized in a category in which the rate is state-set or negotiated and what year that vendorization took place. The individual needs and aspirations of the people this system serves, and measurable success in meeting those needs and reaching those aspirations are divorced, utterly, from the fiscal process and the financial incentives.
I don't mean to imply that this is unprecedented or poor incentive. Lots of California industries reward you for being young.
Another interesting trick of the state system is that rates apply to units of service performed not on deliverables. So, spending all day accomplishing nothing pays better than quick success.
When we talk about "rate reform" in this system, we talk about how people are compensated for the work they do, not about what the state is actually buying.
So, I'm thinking about rate reform and wondering whether the system couldn't get a little more cost-effective by:
Correlating rates with the outcomes sought, challenges presented and the likelihood of success and making level of accomplishment the unit the rates are paid to.
I'd bet on more effective services and lower costs if there were incentives to achieve either.
ZZZZZZZAAAAaaappp
Rate reform means different things to different people but the following applies as a rule.
For vendors: Rate reform = getting more money for doing the same work for the same people.
For government folks: Rate reform = getting more of the same work for the same people for the same money. Quality is subjective anyhow.
I'm indifferent as to whether rate reform should raise the number of dollars coming into this system. I'm zealous, however that the irrelevance of support needed to funding provided needs to change. The failure is nearly total to correlate funding with the resources required to provide the right support, in the right amount, with sufficient quality to produce the outcomes that our clients seek and the State benefits from.
So, here's another primer. This time on how rates are currently set in this system.
There are really three methods of rate-setting. These are state-set rates, residential rates and negotiated rates.
In the most common (state-set) method as I understand it, a new agency receives a temporary rate which is the same for a given category of service regardless of where you are in the State (Inyokern rate=San Francisco rate.) The agency then functions for one year under that rate, fills out a statement explaining that agency's costs over that year and a new rate is assigned. Obviously, if you get the joke, in your first year as a program you spend every cent you're paid and lose as much money as you can afford to on whatever you can in order to produce as high a bill as possible at the end of your first year. The adjusted permanent rate circles over the agency forever, cawing to the great white whale that lurks in the deep. Once in a long while, the state adjusts the oldest rates and those older agencies go from the lowest rates to the highest.
So here's how various factors affect state-set rates, a few years after assignment:
Market value of qualified workers in an area: Irrelevant
Changes in worker's compensation insurance cost: Irrelevant
Cost of appropriate training and skill-building: Irrelevant
Administrative cost of regulatory compliance: Irrelevant
Quality of care provided: Irrelevant
Year Established: High correlation.
In negotiated rates, the agency predicts it's costs, tells the Regional Center what those will be, and then a process takes place leading to a contract to provide services at a given rate. According to the Legislative Analyst's Office, these rates increase at three times the rate of the state-set ones.
Residential rates, as I understand them (and I don't know that I do) works like the state-set rates but with a cost-of-living increase (suspended for several years now) so the correlation between real factors and rates would be like state-set with year of establishment being less relevant.
So the main factors in the level of funding that agencies receive for providing services are:
Whether they have been vendorized in a category in which the rate is state-set or negotiated and what year that vendorization took place. The individual needs and aspirations of the people this system serves, and measurable success in meeting those needs and reaching those aspirations are divorced, utterly, from the fiscal process and the financial incentives.
I don't mean to imply that this is unprecedented or poor incentive. Lots of California industries reward you for being young.
Another interesting trick of the state system is that rates apply to units of service performed not on deliverables. So, spending all day accomplishing nothing pays better than quick success.
When we talk about "rate reform" in this system, we talk about how people are compensated for the work they do, not about what the state is actually buying.
So, I'm thinking about rate reform and wondering whether the system couldn't get a little more cost-effective by:
Correlating rates with the outcomes sought, challenges presented and the likelihood of success and making level of accomplishment the unit the rates are paid to.
I'd bet on more effective services and lower costs if there were incentives to achieve either.
ZZZZZZZAAAAaaappp
Monday, September 06, 2004
Labor Day
It's Labor Day and I'm at work, so consider this passive resistance. It seems like a good time to look at a recent and future proposal for reform to this system. The concept is loose, but Service Employees Internation Union (SEIU) put forward last year a proposal to create workforce service centers in this system. The proposal was pretty controversial, but a variation on it will come soon, so it seems like it deserves a place on this blog for the throngs who read weekly.
The next version of the proposal to come forward isn't known to me yet, so rather than write an endorsement or opposition, I'll just review where I stand on some of what were said to be the pros and cons of the previous concept.
Being long-winded, I'll start with an introduction: The original draft of AB 649 (Wiggins) (a hardly-related rewrite passed and currently awaits the governor's signature or not.) The basic idea was that by legislative fiat, thirteen centers would be created. All staff working directly with people who have developmental diagnoses through Regional Center funding would be employed by the centers and, basically rented out to the agencies responsible for the work. Different drafts of the proposal included different functions but in one or more draft the Centers would:
1. Recruit direct care staff;
2. Pay and provide benefits to the direct care staff (and, possibly, managers;)
3. Provide a fair-hearing process for disciplinary action;
4. Centralize many employment-related administrative functions;
5. Provide core training; and
6. Serve as a launching point for more efficient unionization of direct care staff. (Aye, thar's the rub.)
So, here are some of the arguments made about the concept and the conclusions I naively reached about them:
Hypothesis: "With a Union involved, we'll lose our ability to fire or discipline our staff."
Doug's Opinion: Maybe, but probably not. People with developmental disabilities are far too sympathetic and the system too expensive for an undisciplined workforce to sneak by.
H: Once the workers are unionized, people with disabilities will have a political lion to roar on their behalf.
D: I kind of don't trust this theory. I don't question that the membership and leadership of SEIU (and, maybe AFSCME) really want to do the right thing, and there's no doubt SEIU has more pull in Sacramento than pretty near anyone. Nonetheless, I've complained that the vendor-driven advocacy of the past is narrowed by its perspective and insufficiently challenged by our clients and their families. The same is true of Regional Center-driven advocacy. The same will likely be true if labor unions drive the advocacy.
H: Centralizing some of the system's administration will allow wages to rise without increasing the cost of the system or reducing quality of care:
D: Actually, as long as the operative word is allow (I do need a little wiggle-room,) I agree. 8000 agencies statewide hiring an average of 12 employees apiece can't possibly be efficient. As an example, ¡Arriba!, when we need staff, takes out ads at $80-150 per in obscure places for the purpose of hiring 1 person at a time. Combining that across the hundreds of similarly sized agencies in eastern LA County could provide for big ads in the LA Times, La Opinion and several others. The WSC concept also makes easier self-determination models of care which can be cheaper and more successful for some clients.
H: Having a monopoly on labor for this system is a terrible idea.
D: I'm pretty sympathetic to this argument, especially when you consider the proposals for governance in which someone appoints a board and there's no process for the community to dislodge the boards. When you look at the stubbornness of the failed regional centers, the idea that all labor provided to this system could be connected to similar administrative catastrophes, the concept is chilling. No new self-perpetuating or appointed boards in this system will get my support. Uh-uh.
Happy Labor Day, everyone!
The next version of the proposal to come forward isn't known to me yet, so rather than write an endorsement or opposition, I'll just review where I stand on some of what were said to be the pros and cons of the previous concept.
Being long-winded, I'll start with an introduction: The original draft of AB 649 (Wiggins) (a hardly-related rewrite passed and currently awaits the governor's signature or not.) The basic idea was that by legislative fiat, thirteen centers would be created. All staff working directly with people who have developmental diagnoses through Regional Center funding would be employed by the centers and, basically rented out to the agencies responsible for the work. Different drafts of the proposal included different functions but in one or more draft the Centers would:
1. Recruit direct care staff;
2. Pay and provide benefits to the direct care staff (and, possibly, managers;)
3. Provide a fair-hearing process for disciplinary action;
4. Centralize many employment-related administrative functions;
5. Provide core training; and
6. Serve as a launching point for more efficient unionization of direct care staff. (Aye, thar's the rub.)
So, here are some of the arguments made about the concept and the conclusions I naively reached about them:
Hypothesis: "With a Union involved, we'll lose our ability to fire or discipline our staff."
Doug's Opinion: Maybe, but probably not. People with developmental disabilities are far too sympathetic and the system too expensive for an undisciplined workforce to sneak by.
H: Once the workers are unionized, people with disabilities will have a political lion to roar on their behalf.
D: I kind of don't trust this theory. I don't question that the membership and leadership of SEIU (and, maybe AFSCME) really want to do the right thing, and there's no doubt SEIU has more pull in Sacramento than pretty near anyone. Nonetheless, I've complained that the vendor-driven advocacy of the past is narrowed by its perspective and insufficiently challenged by our clients and their families. The same is true of Regional Center-driven advocacy. The same will likely be true if labor unions drive the advocacy.
H: Centralizing some of the system's administration will allow wages to rise without increasing the cost of the system or reducing quality of care:
D: Actually, as long as the operative word is allow (I do need a little wiggle-room,) I agree. 8000 agencies statewide hiring an average of 12 employees apiece can't possibly be efficient. As an example, ¡Arriba!, when we need staff, takes out ads at $80-150 per in obscure places for the purpose of hiring 1 person at a time. Combining that across the hundreds of similarly sized agencies in eastern LA County could provide for big ads in the LA Times, La Opinion and several others. The WSC concept also makes easier self-determination models of care which can be cheaper and more successful for some clients.
H: Having a monopoly on labor for this system is a terrible idea.
D: I'm pretty sympathetic to this argument, especially when you consider the proposals for governance in which someone appoints a board and there's no process for the community to dislodge the boards. When you look at the stubbornness of the failed regional centers, the idea that all labor provided to this system could be connected to similar administrative catastrophes, the concept is chilling. No new self-perpetuating or appointed boards in this system will get my support. Uh-uh.
Happy Labor Day, everyone!
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