The rub is you can't really root against them because there are clients and vendors being held hostage until the ICBM is certified by the Director of DDS to have been implemented and to be saving the state money. My modest proposal, submit this blog as the complete implementation of the model and certify that you're saving money by canceling the development.
Showing posts with label Dumb Ideas. Show all posts
Showing posts with label Dumb Ideas. Show all posts
Wednesday, November 11, 2009
ICBM outgoing
Last week, I received a copy of the draft of 10 guiding principles for the new Individual Choice Budget Model. A few things I'd note. The first is that after several months there is a draft version of 10 guiding principles for the new Individual Choice Budget Model. That right there is discouraging. The second is that the 10 principles look so thoroughly rhetorical. Protect safety, ensure choice, save the state money. Good ideas, all, and I offer this blog as a pretty good proxy for what five years of work along these lines will probably look like.
Wednesday, March 22, 2006
This year's cost containments
Demonstrating either my clairvoyance or my willingness to talk about matters I know nothing of, a few comments on the cost containments to be proposed by DDS this Spring. It's my workup for the California Disability Community Action Network teleconference so those of you with good fortune to read this before the teleconference will know what I'll say, and those of you listen to the teleconference first can quit reading now.
The cost containment mentioned in the Governor's Budget may include new contract language for regional centers requiring certain Purchase of Service decisions to be made in a certain way. For example, the low-cost provider able to meet the needs of the consumer shall be used and, where appropriate group services should be used rather than one-on-one services. On a common sense basis in which the words appropriate and need have their usual meanings and include a respect for important preferences, this should already be the case and isn't. In that regard, I'm tempted to agree with this proposal.
On the other hand, the first requirement of citizenship is to disagree with the administration and I do. Confidently. Two perspectives seem very difficult for the Department, which make disagreement not only possible but easy.
On the one hand, regulations and statutes and contract language have very little to do with service coordination except in cases where they amount to no and that seems like the better answer to the regional center decision-maker. Many of us here the once-proposed requirement to prefer group settings where appropriate and imagine that it will be quoted and followed faithfully always and only where inappropriate. The low-cost provider who meets the client's needs will be the provider at whatever cost who meets the service coordinator's needs or no-one's. I'll wager that no end-user of this system or vendor will find my claims here controversial or exaggerated.
The second, and more essential perspective missing from this proposal is the understanding that regulations are most often sources of inefficiency and poor outcome. When our system works best it provides a continuum of support to clients that reduces the need for supervision, future assistance and expensive support by assisting the individual to make choices. This is the most cost-effective behavior in our system where the client lives fully and the taxpayers save money. Any regulation, including contract language, of that process inhibits creativity, innovation and motion along this path. Proposals like the one I expect are as likely to freeze a client in an unchosen environment at needless cost as they are to save money.
The cost containment mentioned in the Governor's Budget may include new contract language for regional centers requiring certain Purchase of Service decisions to be made in a certain way. For example, the low-cost provider able to meet the needs of the consumer shall be used and, where appropriate group services should be used rather than one-on-one services. On a common sense basis in which the words appropriate and need have their usual meanings and include a respect for important preferences, this should already be the case and isn't. In that regard, I'm tempted to agree with this proposal.
On the other hand, the first requirement of citizenship is to disagree with the administration and I do. Confidently. Two perspectives seem very difficult for the Department, which make disagreement not only possible but easy.
On the one hand, regulations and statutes and contract language have very little to do with service coordination except in cases where they amount to no and that seems like the better answer to the regional center decision-maker. Many of us here the once-proposed requirement to prefer group settings where appropriate and imagine that it will be quoted and followed faithfully always and only where inappropriate. The low-cost provider who meets the client's needs will be the provider at whatever cost who meets the service coordinator's needs or no-one's. I'll wager that no end-user of this system or vendor will find my claims here controversial or exaggerated.
The second, and more essential perspective missing from this proposal is the understanding that regulations are most often sources of inefficiency and poor outcome. When our system works best it provides a continuum of support to clients that reduces the need for supervision, future assistance and expensive support by assisting the individual to make choices. This is the most cost-effective behavior in our system where the client lives fully and the taxpayers save money. Any regulation, including contract language, of that process inhibits creativity, innovation and motion along this path. Proposals like the one I expect are as likely to freeze a client in an unchosen environment at needless cost as they are to save money.
Tuesday, July 20, 2004
Statewide Purchase of Service Standards
I'll start with a couple of apologies. First, that my laptop was in the shop and I haven't updated this blog in awhile. Second, that this post will be even more arcane than most and probably indecipherable to anyone not well acquainted with California's community-based system of support to people with developmental disabilities. As always, I'll be happy to answer any questions by email.
One proposal for reform which keeps coming up is the one for statewide purchase of service standards (POSS.) This post will explain why this is a bad proposal unlikely to produce the desired outcomes of improving equity or lowering costs while reducing some of the virtues of the current system.
POSS seems at the surface like a reasonable proposal. For those not aware of how our system operates, State law provides an entitlement to people with developmental disabilities, including the criteria by which a person is eligible and the standards that service providers (Regional Centers and their vendors) must meet. The state then provides the Department of Developmental Services with a budget to fund Regional Centers, highly-regulated (in truth semi-governmental, but officially private non-profit) agencies which contract out to vendors to provide services. Those services are required to pursue the individual client's aspirations and reflect that client's needs and preferences. Each Regional Center (RC) has a local board of Directors and a monopoly on providing services to clients in the catchment area.
The intellectual basis for the POSS proposals have focused on concern about significant disparity in how much funding different RCs provide on a per-client basis. This has led some policy-makers to reach two conclusions: The first is that there are major inequities between how clients are served across regions and the second is that the high spending regional centers must be frivolous.
The conclusion was that statewide standards, essentially limitations on what any RC could offer to clients would improve equity and lower cost growth. Laudable goals. Absolutely. They fit with all three basic assumptions in my original post.
The problems come in when one considers how the standards would operationalize. A few more facts about this system before the analysis.
1. The Social Security Act, with which the State must comply to retain the 38% of system funding which comes through our Medicaid Waiver, requires the State to allow for fair hearings when a client feels that they have been wrongly denied a service or support. This requirement is not waivable as part of the Medicaid Waiver program.
2. There are two ways money gets wasted in this system- POSS is designed to prevent the waste that comes from state funds being spent on services or supports which are excessive, don't help or are otherwise inappropriate. The other is when services or supports are denied which would have allowed a client to live in a less costly, less restrictive setting.
3. The challenge that all RC staff face is that there is rarely clarity as to how the risks mentioned (in 2.) above are balanced.
4. California's regulations require an exception process for most RC purchasing policies to allow for unusual conditions in which the standard policies will fail to account for a legitimate need.
As a consequence of the four facts above, most client's receive services within their RC policy guidelines but some do not. When policies are applied which a client or their family/guardian/conservator feel should be waived due to health and safety needs or in order to allow the client to live in a less-restrictive environment, there are two processes (exceptions to policy and fair hearings) which allow the interested party to appeal for a different service decision.
Although the POSS proposal creates an exception when service limitations would cause someone to move to a more restrictive setting, the question is: How will that be determined. At the more liberal RCs, that finding will often occur. At the more restrictive ones, pretty much, the finding will occur only for board members and their families. As a result, actual behavior needn't change at any of the regional centers. The one difference will be that in the rare occassion that a client files an appeal, the likelihood of an RC decision being overturned is reduced because the RC will have been following state regulations rather than its own policy in denying services.
In other words, the likely result of POSS may be a small increase in the inequity of the system as liberal RCs retain the tools to remain so and restrictive RCs are emboldened to be more so.
So, POSS is unlikely to achieve it's objective vis-a-vis greater equity. What about cost?
That really depends on whether the funding wasted on inappropriate, ineffective or unhelpful supports will be reduced by the money wasted when decisions are made which lead to clients in more restrictive settings. Neither the sponsors of POSS, the writers of it, or I have any credible information to make that judgement. What information exists is interesting, though:
The RCs in LA County generally considered to be the most liberal in their POS policies also happen to have the lowest expenditures on a per client basis. Although there are a lot of possible explanations for the differences other than good policy-making, it is compelling that the evidence doesn't support the principle that for our system, conservatism and stewardship go together.
Ultimately, POSS would have reduced the individualization that is the moral core of this system with little promise of lower cost or greater equity. It may represent the best thinking of California's Department of Finance but we do better thinking in the community. And at DDS. The next post will be about some reforms with more promise being worked on at DDS and in the community.
One proposal for reform which keeps coming up is the one for statewide purchase of service standards (POSS.) This post will explain why this is a bad proposal unlikely to produce the desired outcomes of improving equity or lowering costs while reducing some of the virtues of the current system.
POSS seems at the surface like a reasonable proposal. For those not aware of how our system operates, State law provides an entitlement to people with developmental disabilities, including the criteria by which a person is eligible and the standards that service providers (Regional Centers and their vendors) must meet. The state then provides the Department of Developmental Services with a budget to fund Regional Centers, highly-regulated (in truth semi-governmental, but officially private non-profit) agencies which contract out to vendors to provide services. Those services are required to pursue the individual client's aspirations and reflect that client's needs and preferences. Each Regional Center (RC) has a local board of Directors and a monopoly on providing services to clients in the catchment area.
The intellectual basis for the POSS proposals have focused on concern about significant disparity in how much funding different RCs provide on a per-client basis. This has led some policy-makers to reach two conclusions: The first is that there are major inequities between how clients are served across regions and the second is that the high spending regional centers must be frivolous.
The conclusion was that statewide standards, essentially limitations on what any RC could offer to clients would improve equity and lower cost growth. Laudable goals. Absolutely. They fit with all three basic assumptions in my original post.
The problems come in when one considers how the standards would operationalize. A few more facts about this system before the analysis.
1. The Social Security Act, with which the State must comply to retain the 38% of system funding which comes through our Medicaid Waiver, requires the State to allow for fair hearings when a client feels that they have been wrongly denied a service or support. This requirement is not waivable as part of the Medicaid Waiver program.
2. There are two ways money gets wasted in this system- POSS is designed to prevent the waste that comes from state funds being spent on services or supports which are excessive, don't help or are otherwise inappropriate. The other is when services or supports are denied which would have allowed a client to live in a less costly, less restrictive setting.
3. The challenge that all RC staff face is that there is rarely clarity as to how the risks mentioned (in 2.) above are balanced.
4. California's regulations require an exception process for most RC purchasing policies to allow for unusual conditions in which the standard policies will fail to account for a legitimate need.
As a consequence of the four facts above, most client's receive services within their RC policy guidelines but some do not. When policies are applied which a client or their family/guardian/conservator feel should be waived due to health and safety needs or in order to allow the client to live in a less-restrictive environment, there are two processes (exceptions to policy and fair hearings) which allow the interested party to appeal for a different service decision.
Although the POSS proposal creates an exception when service limitations would cause someone to move to a more restrictive setting, the question is: How will that be determined. At the more liberal RCs, that finding will often occur. At the more restrictive ones, pretty much, the finding will occur only for board members and their families. As a result, actual behavior needn't change at any of the regional centers. The one difference will be that in the rare occassion that a client files an appeal, the likelihood of an RC decision being overturned is reduced because the RC will have been following state regulations rather than its own policy in denying services.
In other words, the likely result of POSS may be a small increase in the inequity of the system as liberal RCs retain the tools to remain so and restrictive RCs are emboldened to be more so.
So, POSS is unlikely to achieve it's objective vis-a-vis greater equity. What about cost?
That really depends on whether the funding wasted on inappropriate, ineffective or unhelpful supports will be reduced by the money wasted when decisions are made which lead to clients in more restrictive settings. Neither the sponsors of POSS, the writers of it, or I have any credible information to make that judgement. What information exists is interesting, though:
The RCs in LA County generally considered to be the most liberal in their POS policies also happen to have the lowest expenditures on a per client basis. Although there are a lot of possible explanations for the differences other than good policy-making, it is compelling that the evidence doesn't support the principle that for our system, conservatism and stewardship go together.
Ultimately, POSS would have reduced the individualization that is the moral core of this system with little promise of lower cost or greater equity. It may represent the best thinking of California's Department of Finance but we do better thinking in the community. And at DDS. The next post will be about some reforms with more promise being worked on at DDS and in the community.
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