Did DDS cut something correctly?

When I hear from worried vendors concerned about cuts, much or most of the dyspepsia is over the limitation to 15% administration in negotiated rates. There certainly can be a case against that cut. People who live on their own and can't use the commonest forms of communication are highly vulnerable and for those of us who serve such people, their best protection is not the regional center, or the area board or in many cases families but oversight from the administration of their service provider. Furthermore, to the extent that we are careful and detailed as a system, there will be many cases when service designs will have to be revised to bring down overhead and those revisions may not have a smooth path to follow.

However, my instinct tells me that the greatest flaws in the budget-cutting regime over the last years has been the combination of rigidity with uncertainty. Consider my personal black beast, the new audit requirements. The cost of that requirement, it seems safe to predict, will reach the tens of millions of dollars per year systemwide in purely administrative costs. Those costs are real, certain, specific, mandatory and tangible. But the mechanism by which that requirement will save the state money is hypothetical. To be kinder, I suppose we could say hopeful.

By comparison, the 15% cap can be at least anecdotally supported as a way of saving money and the combination of vendor, client and regional center have a fair degree of flexibility to decide what features of the support should be sacrificed to reach a clear threshold. Of course, the same combination is also empowered to launder their way out of savings via reclassification of effort, but still. To the extent that it works, the cut can be tailored to protect the needs of the consumer, the competency of the provider and the preference of the regional center.

Apart from Stanley, anybody out there want to give DDS credit for this? Or are there other cuts that seem smart to you?

Things DDS (or LAO) should be thinking about, Part I

While DDS plays with service standards and administration costs and other proposals from which the unforeseen consequences will outnumber the planned reforms by 1,000 to one, there are some foreseeable scenarios for which planning could mitigate harm and reduce costs. Here is my list:

Consolidation is inevitable. The cuts the governor has proposed are more than the system can bear, but even without further cuts, many agencies are now unsustainable and there will be further cuts. What's more, there is no likelihood that the cuts as proposed will be the cuts as experienced. Things intended no longer to be compensated will be paid for and things left protected will be cut. Agencies will reach the point that they are no longer large enough to justify management and those agencies will start to close. The clients served by those agencies will in most cases receive new supports from different agencies.

Barriers to sale or merger of existing agencies can be removed, allowing the clients to avoid interruption of important relationships and lowering the administrative burden on both regional centers and vendors from the reallocation of those clients. The alternative is the existing process which is needlessly traumatic for clients and staff and needlessly costly for agencies and the state.

The savings in the Bureau of State Audit reports are between the headlines: So far, trailer bill language coming from DDS seems focussed on the most lurid offenses the BSA found in its work. I can certainly agree that IRC's budget-padding ought to be cut off and extra funding for relatives of regional center employees ought to be cut off. But booking savings seems foolish. It strikes me unlikely that any new statute will prevent miscreants and thieves employed by regional centers from spending any new money in ways that their colleagues have been caught.

But between the headlines were examples of how regional centers may waste money in small ways every day. To someone working in this system, a family member of someone who is a client in this system, the anecdote of the regional center employees explaining a contracting decision with an undocumented, unexplained preference resonated with countless experiences repeated so regularly I'd stopped noticing until I saw it in print. The new trailer bill language regarding large contracts might have prevented one $950,000 absurdity but perhaps never another. Reviewing vendor selection by regional centers by sampling the tens of thousands of opportunities that arise each year to be unintentionally inefficient holds much more promise.

As someone who has encountered both wild bears and domestic termites, I assure my friends in Sacramento that common, small pests do much more damage than big rare ones.

Look differently at rates: One way this system was meant to be efficient was competition. The problem is that there has never been a good tool for regional centers to use to reliably (or semi-reliably) judge quality and rates are opaque, so whatever providers compete on the basis of, it isn't quality and it isn't cost.

This has a couple implications. First, rates should be public so that agencies can compete on that basis. Second, it means that for the most part, the state is paying whatever rate was given to whatever agency was chosen on whatever basis. In the short term, if further rate cuts are anticipated, given that the rates are close to random, it would be better to cap rates than to continue hurting the low cost providers by the same percentage as the expensive ones. The usual justification why the rate system is so irrational has always been that to rationalize it would cost some agencies and they'll fight the change. That's still true, but seems pretty important in the present circumstances.

But rates ought to public and regional centers and/or DDS ought to publish them. That will make it a little harder for regional centers to neglect that consideration and a little harder for high-cost vendors to hype their own costs. Furthermore, it would help in negotiations as the fear of being cheated could be as completely allayed as it is possible to allay that particular phobia.

Query to readers: What do you think DDS should be considering while they write the trailer bill language? (Leave a comment and then go tell them.)

Talking cents

The dollars needed to preserve the system will not be forthcoming, I'm afraid. Not for a long time, anyway. I believe our choices will be to let it all continue to crumble or start seeing nickels and dimes worth of actual service as more desirable than advocacy denominated in billion dollar bills.

In support of a resolution I've proposed to the San Gabriel/Pomona Regional Center Vendor Advisory Committee, I've recently had the opportunity to retell this story: In 2002 or so, I started receiving a lot of phone calls from Service Coordinators asking me questions that took me by surprise. But they had a pattern: Many asked about the clients' height and weight (useful mostly if you are going on rides at Disneyland or boarding a helicopter;) some asked about the clients' ambulation (useful for special olympics planning;) others asked if the client had been out of service for any extended periods, out of state or hospitalized or in prison (useful for identifying fraud, assuming the same vendor would bill fraudulently and then answer the question diligently.)

The questions were odd and there was no particular place for me to find the answers, so after receiving the calls I would generally get up, search through the client's file and, if that didn't turn up the answer, call the supervisor responsible for the case who would, next time she wasn't with a client search through notes for the answers. Then I would call the SC back with or without the right answer. I don't know how much time SCs were spending on the questions, but Arriba staff were spending several hours per week.

At some point, I found an unimpertinent way of asking "why are you asking?" and the answer came "for the waiver documentation" nine times out of ten. After that I talked to the very smart person in charge of said documentation and we worked out a template, to be included in every progress report, that would answer all of these questions. Staff already, when updating the reports looked in all the places that data would be for the answers to other questions so once we changed our template, the administrative workload here went down sharply and at least some time was saved for the SCs who eventually would learn that the answer was sitting on their own computer. At the very least, the calls per client-question fell from two to one.

Spread that change from Arriba's 100 or so clients to a regional center's some-thousand-and-some, and it might be that half a year of one person's work could be saved. That's not a ton, but it could be enough to turn an administrative position into a service position or a savings.

So, here's a question for commenters who seem to need questions: What are some other small changes that might make the cost of service left while leaving the service intact?

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.

Serving Stanley for Free

In the comments for the previous post, Stanley asked:

"Thanks for providing specific provider details...hate to push one so willing to provide such information...butbut wondering how do rates compare with actual cost of providing quality programs...do rates paid by RC cover all cost of providing quality support...are all IPP needs/goals covered by rates.

Questions arise based on process used to determine cost of providing support for my daughter...eg/ie, agency gave RC cost to provide support...RC either approved or denied these cost...I do not recall any mention of what rate would apply...there was no discussion of an agency who could provide same support for less...did such an agency exist...how does one quantify/equate lower rate and program quality.

And among many things I have not seen is a list of state-set rates...there seems to be a disconnect between rates, cuts and cost...also

How do cuts effect Lanterman entitlements...ie/eg, Though DDS wrote that it will maintain the entitlement of the Lanterman Act, it simultaneously wrote that it would mitigate the expenses associated with the growth in population?"

Here are some thoughts, I invite readers to add their own:

1) I am absolutely certain that rates and quality are not perfectly or even well correlated. There are a lot of things that cost money to do badly and are free if you do them well. Just as a quick example, with individualized services, there is always a tension between management's idea of how those services should be provided and the end user's. There is always a fiduciary concern that the client's money be spent appropriately pitted against the client's interest in having their money spent according to their wishes in a timely fashion. An agency can spend a lot of money imposing the management's interest while many clients provide their own vision for free. This is just a theory, but I have long suspected that leaner individualized supports are probably much more person-centered supports.

To agencies like ¡Arriba!, fairly lean individualized providers, the most important benefit from better funding is staff retention. But if management is injudicious or unwise in who gets retained, as I confess to having been on a few occasions, then quality doesn't benefit. Good funding can allow management to be too comfortable trusting staff and allow people who could more productively do something else stick around longer. So better rates can improve or erode quality, depending on the willingness of managers, staff and clients to make difficult decisions before making payroll becomes a maybe thing.

A few cautions, though: A lean, quality-focused, person-centered agency most likely will see quality go up and down as rates do. I guess my answer to that part of the question is that the impact of budget cuts on accessibility is more obvious than the impact on quality. Another caution is I know even less than DDS and the regional centers what the factors of quality in a congregate support are. It may be that as services become more intentionally programmatic, standardized and institutional that funding per unit of service has a simpler and more positive correlation with quality.

2) The connection between rates and the IPP is obvious if you are talking about SLS or the total Regional Center POS budget. Otherwise, the IPP is purchased by buying units of service that may not be through the same vendor code or agency. At ¡Arriba!, for example, we can support every part of a client's IPP at our new, lower rate but the cost goes up because we have to add hours of service for each goal we work on with a client. I understand that for SLS clients and SDS clients the "rate" is a composite of costs pursuing different parts of the IPP so it would surprise me if an SLS provider could say yes in answer to your question. I can, though, provided I am given enough authorized hours to juggle it all.

Obviously, if the POS budget is capped this year (but exists) then some IPPs will have to get less ambitious. That might even be a good thing if we could trust people to prioritize wisely and thoughtfully. If anyone reads this and trust that IPPs will diminish wisely and thoughtfully, please let me know in the comments. I'd sure like to hear it.

As to your comment about the disconnect you perceive between rates, costs and cuts- I can only agree. It's madness. A herd of cows would design a more rational system. A pack of wolves would design a more honest one. A cabal of cannibals would design a more defensible one.

**Update** Through the good offices of a good friend, Stanley, here is the list of rates and rate-setting mechanisms:

Dreaming with the Governor

While we're waiting for work to be done by the legislature, and since I haven't posted here in a month, I have some thoughts about one plank in the Governor's proposed cuts to DDS. One of the elements of the cost-cutting plan calls for Regional Centers to refer clients to the lowest cost provider of the desired service who is able to meet the requirements of the client. My agency seems to be the current low cost provider of individualized supports serving the SGPRC catchment area and, perhaps, the ELARC catchment area as well.

In a way, this is a better bad policy than most, at least from the provider perspective, particularly where agencies with state-set rates are concerned. The biggest budgetary risk from the rate cut implemented February 1 will be that vendors with already low rates close and are replaced with agencies whose rates remain higher than those charged by the low-cost providers before the cut. In fact, when the rate cut went through, ¡Arriba! was the second lowest-cost provider and remained so until our better closed in April. The risk is that unit costs rise or, at least, the overall affect becomes uncertain.

One smart way to avoid that trouble would be to cap rates rather than lower them proportionally. In that case, high-cost providers would be forced to charge less and if they failed to restructure their costs, they would be more likely replaced by lower-cost vendors.

But the proposal makes some sense, too. Under it, lower cost providers are to be strengthened after the proportional cuts through higher volume. This should help preserve the lower-cost providers. Setting aside for the moment my usual bitterness that the system should be so vendor-centered, at least the budgetary intent has a better shot with this proposal implemented.

Except it probably won't be implemented. I have very little hope that this agency will see more referrals. Regional centers are already incented to and expected to use the low-cost provider able to meet the clients' needs. When the previous low-cost provider closed, how many of their former clients were referred to us for service? Exactly. Even in the middle of a financial crisis that forced the regional center to cut hours, the lowest-cost alternative wasn't used.

So worry not, my friends, about this particular piece of trailer bill. Should it pass, your friends and loved ones will not be herded into low-cost programs but will continue to enjoy the higher-cost services of whatever quality they now receive. Hopefully, the cut was scored conservatively.

Save your self(-determination)

On this blog, we have discussed SDS (self-determination or self-directed services.)  For examples, you can click here (and please forgive the self-referential first result.)  I have tended to argue stridently for self-determination in concept and ambivalently for self-determination services as proposed and grouchily about SDS' roll-out.  Now SDS seems dead after an unfriendly end-of-life. But the basic concept still seems relevant, particularly with the traditional DDS system wheezing and scowling.

So, a first question would be what was the basic concept?  If you read the languishing proposal to the federal government, you don't know.  But I would argue that the basic premise was that the individual level is the best one for identifying and addressing the needs of an individual.  

When you look at what SDS offered, there are obvious efficiencies available under a person-centered service regime which can save the state money and improve benefits.  Now that the SDS movement is on the shoals and it's cargo poisoning seals, we have an opportunity to consider whether what was important in SDS remains viable and worth salvaging from the wreck.

Self-identification of needs and solutions remains, in theory, the official law of the land and the funniest joke in the villages.   There exist more than one way of putting the I back in IPP/IFSP.  Certainly, the preference for providing supports by availability rather than appropriateness allows a great deal of waste in our system, of state funds and client energy.  This ought to remain a focus in bad financial times more than in good ones.

Administrative cost will continue, I'd think, to be under pressure.  Instead, this is what advocates seem to defend most passionately.  Clients who are able to protect themselves don't need to be paid to do so.  Clients who are able to advocate for themselves don't need to be paid to do so.  Clients who can judge among available options for their own goals don't need to be paid to do so.  So why hasn't the devolution of the purchase and oversight power of regional centers and vendored executives come under attack with the community budget, for those clients able to take up the same task?  Even the development of SDS empowered regional centers, progressively, to apply themselves to tasks capable individuals will do for free.  

Throughout our current budget fandango, deregulation continues to not come up as a means of reducing fiscal pressure.  It ought to be remembered that beside stifling innovation, regulations always have a fiscal cost as well.  A correct system will balance the cost of regulation and supervision against the not unreasonable fear of liberated vendors.  SDS offers a terrific vehicle for testing a more person-centered regime as a cost-effective means of oversight, but even without SDS, some rebalancing is called for.

Unvendored services still offer more cost-effective resources for many currently vendored efforts.  As long as the only way some ¡Arriba! clients can reliably carry out normal activities is by ¡Arriba! employee chaperones, we will continue to provide that assistance at our new, low, low rate.  But there are a lot of trips for which a neighbor with a Camaro and twenty bucks for gas is an almost perfect substitute at half the cost.  SDS was a useful model for testing the safety and availability of unvendored providers of unskilled services.  Even without SDS, policy-makers ought to be broadening system resources. Unvendored services can often be more integrative and inclusive than vendored ones.

Without a formal SDS proposal, some of the the composite policies still offer relief to a stressed system.  The development of those policies, in turn, can increase the level of self-determination in our system.  SDS may now be decomposing and might have started to decompose premortem, but before we bury the remains, it's worth seeing if there aren't some nutritious bones left in the carcass.  If we aren't that hungry yet, we are likely to be soon.

The Governor's New Proposal

Well, that was fast. The three-month late annual budget lasted six troubled weeks and now the legislature is back in session, ordered by the Governor to redo the math. In the governor's proposal is a 3% payment reduction to regional center vendors and a 3% cut to regional center operations. Vendors and regional centers would be hurt a little. Also on the table are cuts to SSI/SSP, IHSS and MediCal. People with disabilities could be hurt a lot.

What ought to also be considered is how to make some of the cuts less damaging. For vendors and regional centers, that means relaxing some compliance costs. While the transition to genuine and efficient outcomes-based accountability will remain beyond the scope of the special session (and the grasp of the legislators,) authority could be given to DDS to reconsider some of its regulations on a cost-benefit basis. As of right now, regional centers and vendors have the power to reduce some of our more paper-centered activities. While accountability of some form is absolutely critical, there is a conflict between cost and agility on the one hand and compliance on the other. I suspect if we looked more analytically and honestly, we'd find we err far on the latter side. Of course, if we were more analytical and honest, we'd all be bankers.

Channeling Paul

In the comments to the post below, Paul wrote: 

Doug,

Have you noticed that over the last several years we have “hammered out..” a budget that actually shrinks our opportunitu to hammer out one in the future? What I mean is this…

As we shift more and more to federal funding as an answer to our budget we become more and more enslaved to the whims of federal budget makers. Is this the Sacramento’s fault? Ultimately I would say yes, after all they are the ones that say yeah or nay.

But lets be fair – we do not need to search far to find fantasies and fallacies about unmatched state dollars, waiver, backfill, and outrageous numbers like 1.4 Billion in untapped federal monies. In fact, we do not need to search at all. The advodivas, the advocrates – the politicians are within our own ranks.

How can we not love a person that implies through poignant protestation that we are being short changed 1.4 Billion dollars? We love him or her just as we love the politician that tells us that he or she will cut our taxes and double our entitlements at the same time.

Until we can address our realities Andy words are axiomatic, “It does not, will not, cannot exist in our government.” Until we acknowledge that some of our efforts at home are, “little more than the brightly-colored bunting and balloons of a democracy”

I have noticed, just as I noticed that you said articulately something I've been trying to squawk out for the lifetime of this blog. Missing from his list is the amount of time, energy and audience we waste debating the prevalence of "classic" autism.  There are a few problems that I would identify in our approach:

1.  We argue with the idea of waste in the system before looking for it.  If there is waste in the system, and we all know there is, it is interfering with effective support for people with disabilities and counteracting the well-spent funds.  If there is waste in the system, identifying and eliminating it would be that much funding we would not have to defend.  That we find so many ways to fight against the unexamined implication also allows those who would cut our finding to decry wasteful spending without expectation of quantifying it.

2.  That we even care what resources might be available takes the conversation away from the mission and into the money.  We will never win an argument about money.  We have people who need and deserve our support.  They are compelling people, sympathetic people and above all, people.  It is easy to not care about acronymmed arcana like FFP.  It is hard to dismiss a human striving to overcome a profound challenge.

3.  Nothing depresses me more than the number of my dear friends in the DDS advocacy community who have been saying for 8 years that we can't start the important fight until funding is secure.  Funding will never be secure.  As long as you think funding comes first, you have surrendered the battle for everything you say matters.

Capitalism, Freedom and Inclusion

I have been re-reading Milton Friedman's Capitalism And Freedom, may God have mercy on my wretched soul.  Here is a passage I find relevant to the discussions here:  

"The characteristic feature of action through political channels is that it tends to require or enforce substantial conformity.  The great advantage of the market, on the other hand, is that it permits wide diversity."

 Far more elegantly (and probably more glibly) than I have done, Friedman makes the case that I have tried to make (e.g. here and here,) that in asking DDS to provide too many assurances we not only create inefficiencies in the system by encouraging more central planning of the lives of the individuals served, we also undermine the inclusiveness the society we claim the intention to open.  Following Friedman's argument, the more activist we ask DDS to be, the less able our system will become to model the inclusiveness we promote. 

"...a major source of objection to a free economy is precisely that...it gives people what they want instead of what a particular group thinks they ought to want.  Underlying most arguments against the free market is a lack of belief in freedom itself."

Incidentally, openness to diversity includes patience with extreme nerds,  For those interested, the reason I am rereading this book which was written the way Alan Greenspan speaks is an online book club being hosted by Free Exchange, the economics blog sponsored by The Economist newspaper's online entity.  Anyone unlovable and fascinated may wish to participate but please behave and don't tell them I sent you.  My subscription is my only friend besides my dogs, and they're Keynesians.

Families and Reform

The Apostle Stanley is stirring it up in the comments in the post below this one, comforting the afflicted and afflicting the rational.  His comments have inspired some thought on my part, no mean accomplishment.  

If you look through this blog over the years, those reforms I argue for most consistently: transparent and public outcome evaluations of programs and policies, self-determination and its pale cousin self-directed services and value-stream management share a common assumption: That end users of the system, given the means and opportunity to do so, will choose quality supports providing the maximum likelihood of achieving the client or families goals.  It is on this basis as well, that I tend to kick against top-down, regimentary solutions such as those Stanley suggests.

I make this assumption in direct contradiction to some experiences I've had.  I am often at meetings with groups of clients and/or family-members gathered for the purpose of advocacy.  Often at those meetings, complaints are rife towards service providers and regional centers.  The commonest answer to "have you discussed this with your agency/regional center?" seems to be "I am afraid they will retaliate."  The commonest response to "Have you considered changing agencies/service coordinators?" seems to be "It's a lot of work and, anyway, the next one might be worse than the last." 

I recently told a good friend after one such meeting of my suspicion that if mediocrity in a service provider cost money, excellence would abound.  Likewise, I suspect that if listless service coordination made extra work, service coordinators would struggle to be responsive.  

I am sure fears of retaliation aren't entirely unjustified and I certainly grant (and assert) that discovering quality supports is impractically hard.  But, if end users won't seek alternatives to poor service, then Stanley is probably right, the only way this system will get any better is a top-down process that will also make it less creative, innovative and diverse.

Well, that was kind of sensible, mostly

As some of you might have heard through a friend of a friend, the Governor's May Revision of his budget is out. It did not live up to the Cassandaric expectations that I and others had. There is no apparent further cutting to DDS' budget, although there are further reductions due to lower caseload which can mean either (A) we have looked at the data and the trend is lower than expectations or (B) we have some evil plans so subtle that to announce them would be like putting marzipan on a gourmet gateau. It will be worth asking questions about that. 

In some ways, I have to say I'm a little disappointed. First and least, because I think the sustainability and stability of funding is more important to what we do than sufficiency, and I'm skeptical that such a large budget gap can be honestly solved without more pain (and fewer 'S's.) Secondly and more importantly, because this system is so reluctant to change, even for improvement's sake that budget crises are usually the minimum requirement to discuss reform. Thirdly, I'm pre-emptively disappointed because the various associations, providers and regional centers are generally much more vigorous in defense of Regional Center cuts, than when the cuts bypass agencies and harm clients directly as is the case in the May Revision. The eye-catching cuts are to CAL-WORKS, which many people with disabilities use, IHSS which many people with disabilities use and Medi-Cal which most people with disabilities use. 

So the question is: If we could reform the DDS system to provide more value with less money given a promise* that any savings would go to backfill IHSS, Medi-Cal and/or CALWORKS what would we, as a community, do? If the answer is nothing, we deserve much worse treatment than the administration has so far given us.

*I'm not sure it would be wise to believe that promise, although "why save money for people with disabilities to protect prison guards" is both a realistic and depressingly cynical response.

***6/5 Update: I learned a new blogging trick, by Jim.  Comments are currently closed on this topic but open on all others.  If you find this outrageous, please contact me or leave a comment in the post above.  If anyone wishes to email me and doesn't have my address, it can be obtained by clicking on my name under "Contributors" above and reading down the left hand column of my profile.

What's not in the DDS Report, Controlling Regional Center Costs, Part II

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 individual
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.

I 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.

What's not in the DDS Report, Controlling Regional Center Costs, Part I

OK, first of all, my purpose in adding this post is not to cut off commentary in the post below. Feel free to read and comment on either (or neither.) But I am in the mood to expand on my own snarky comment regarding socialism. Here is the first of some ideas I would have added to the DDS report had it been my honor to write it. This will be the first in a series of one or more proposals to control regional center costs and improve service through deregulation.

Eliminate vendor codes: Whatever the intention of the vendor codes, the principle functional purpose they rightly serve is to limit the breadth of service a single provider can offer, lowering the quality of the services vendors provide. The (likely) unintended function is to foster service denials by implying, at least sometimes, false redundancies. This reduces the flexibility of Regional Centers. A tertiary function of the service code is to waste regional center operations budgets on distractive, unproductive idiocies which then discredit the notion that non-profit boards provide guidance.

Finally, vendor codes probably add administrative costs needlessly by requiring different needs to be met under separate administrative arrangements. For example, if a person receives job-coaching but also needs help budgeting, cleaning their apartment and socializing, that person will generally be helped by three different agencies or at least three separate divisions of one agency with separate staff for the employment assistance, living skills and social assistance. This means the state pays for the liability insurance three times, the administration three times and the training and recruitment three times at the vendor side and the quality assurance three times, the service coordination three times and the billing three times on the regional center side. (Plus all the unproductive time spent by core staff at regional centers trying to cleverly craft changes to the purchase of service policies and get them rubber-stamped by glassy-eyed board members.)  Meanwhile, the client gets possibly triple the number of people to work with and is at risk that some need will not be met due to limitations placed on the vendor categories.

The vendor codes help the regulations to address specific service designs that address specific needs specifically but there are two reasons this might not actually be helpful. First, if you read the service standards portion of the California Welfare and Institutions Code, Title XVII - Division 2, Chapter 3 which defines the service codes and cross out all the regulations that are not typically monitored or enforced, too vague to provide clear guidance or that essentially self-repeal (cf section 56742 (a)(3-4)) you might easily be left with nothing but paragraph numbers and the vendor codes themselves anyway. The second reason this might not be important is that it is a fundamentally agency-centered approach and directly contrary to the person-centered approach we pretty much all claim is holiest and most efficient. (Note: This last point is the commonest hypocrisy in our system and your correspondent is usually guilty of it before swallowing the lees in his first cup of coffee.)

(Anecdote warning) My biggest regret from all my time in this field is this: Once upon a time, when I had done this work for about a year, a man who gave his name as Michael called and said he wanted to hire ¡Arriba! using his own money because he was living in a group home and the "independent living training" he got from the home wasn't helping him to move out (!) on his own. He said he had asked for ILS training from Lanterman Regional Center and been told that ILS services were not available to people who live in group homes because the group homes were supposed to provide that help. The thought of letting a client pay privately for services the regional center center should have provided was appalling but I have regretted ever since not asking his full name or offering help to get ILS into his IPP. This anecdote serves two purposes in this post: The first is as a caution that sometimes it can be a very good idea to have more than one agency provide services to the same individual, such as when there's a conflict in interest like expecting a residential facility to help an individual move out. Second, that while I sadly do not know the details of this case and there may have been logic to the regional center decision, it is not hard to imagine a case where a situation far better for an individual and far less costly to the State was foiled by a policy defined in terms of vendor code. Can anyone imagine a case where needless expenditures are reduced or client value added through categorizing services?

Advantages/Disadvantages: Advantages of this option include (1) Cost-savings through reduction of unnecessary administration, (2) improving the flexibility of service providers including regional centers and their vendors to be of use to clients, (3) simplifying the regulations, (4) a key step toward value-based rather than cost-based budgeting, (5) a person-centered approach to service design, coordination and implementation and (6) reduction in greenhouse gas emissions. Disadvantages include (1) costs related to retraining senior management at several regional centers to do something productive or replacing same, (2) creepy feeling that once-reliable service boundaries are giving way to free love and poetry slams, (3) priestly positions lost, some unionized and (4) loss of scale economies related to optimum use of the boards' rubber-stamps.

Total Savings: Indeterminate.

Hey, look, the DDS folks get paid to do this. You have to admit, though, green for advantages and red for disadvantages was inspired.

**UPDATE:  A good friend who is also scary smart just emailed that CMS requires service codes for the waiver, which is either a deal-breaker or a proposal-changer, depending on A) what level of definition CMS regulations require of the service code and B) how the service codes are required to be applied.  California defines programs by service code, but if CMS does not require that it may be possible to code for instance, activities or needs rather than programs after the fact.  This was how hospital billing was often done back when I knew about hospital billing.  Also, depending on CMS' definition of service code, it may be possible at least to broaden the definition to achieve some of the goals in this proposal.  For example if there were one service code for housing and supervision, one for medical supplies, one for each regulated professional service and one for all others including SLS, day programs, ILS, supported employment, respite, social/recreational, waste, fraud and abuse.

Controlling Regional Center Costs.

The California Department of Developmental Services (DDS) has produced a document entitled "Controlling Regional Center Costs."  (You can click on the title of this post to download it or read it in your browser.)  To my eye, the document is very carefully written not to give license for foolish cuts.  Once you have read most of the proposals contained you would have to be as dumb as box of rocks to consider smart.  Also, for those in the panicky state of fretting that this report represents an assault on the entitlement or a murderous conspiracy, it ought to be noted that some of the most favorably described cost control measures are preventive, such as investments in better dental care, expanding employment and affordable housing.  I would give some laud and honor to the writers for careful wording. 

This may be the first of a series of posts on this report, the next likely to deal with selected proposals but start with two questions:

Given the past experience of DDS reports and their influence on policy-making, is it likelier that advocates will pay too little or too much attention to this?  The Service Delivery Reform report opened few doors in Sacramento but it has held a lot of doors open.

Why is socialism the only answer to reduce government spending?  An ongoing frustration of mine is that all the virtues of the Lanterman Act as a mechanism for efficient, responsive care depends on innovation, creativity, liberty and choice.  It continues to depress me that centrally defining, regulating and limiting what can be done is always the response of government, and frankly, of most of our advocates.   We love to talk about innovation and creativity, never more than when we find some new way to instruct our neighbor.

And, friend Paul, I promise that none of the posts regarding this document, if there are more, will discuss or promote funding as a purpose or point.  That's not what I do here, and really isn't what I do in Sacramento either.

An illustrious and heuristic new year to us all

So, an anonymous friend or stranger, commenting in the post below, reminded me that I started this blog to be an undisciplined but thoughtful problem-solving forum.  A cruel reality that I think needs to be held up before I return to my original purpose is this:  This year's "reform" discussion is doomed to stupidity because no credible and systemwide effort to measure, identify, examine or rationalize what actually happens in this system has been performed and the pressures against the cost of the system are too urgent.  I expect smart and well-intended people using all the information tools available to put forth ideas for gently reducing the funding our system.  Those people, if they believe they know how the system works now and where the problems are have over-rated their guesses and gossip. 

But, maybe in the midst of the coming catastrophe, there will be opportunities to talk about accountability, transparency and adding features to the system that will make it smarter.  Here's my new year's list of topics I hope will be seriously discussed.

1.  Those of us with client-level perspectives know that the regulations guiding this system are routinely not followed.  In the end, we need to decide if we believe that a client-centered system is truly more valuable and more cost-effective.  If we do, we need spare and judicious regulations routinely followed with consequences for those who ignore the rights of clients to guide their program plans.  

2.  Efficiency, the economic concept, unlike the political euphemism, "efficiency," is the heart of justice.  In an efficient system, some of us would lose our jobs but those most vulnerable in the system including clients, direct-care workers and families would be likelier to benefit from the money and effort spent.   The honest definition of efficiency is the value added for the cost expended.  Skilled and management workers need to understand that a more efficient system might need some of us less, but moral individuals should be ready to be counted in that number.  I can still fix old cars and might get my roping back with practice.

3.  The system needs to get much, much smarter.  We don't measure and track outcomes.  At the policy level there is no hopeful way to direct resources where they will help the most.  At the client level, there is no reliable way to choose the most helpful support among alternatives. The cost of neglecting the intelligence of our delivery model will be tragic this year.  If vendors, regional centers, unions or other stakeholders seek to delay or deter transparent evaluation and easy access to information about quality, they deserve to be ignored or over-run.  It is a very late hour to start this conversation in earnest.  

4.  There is real magic available in self-directed services.  The regulations are too many and the funding too sparse for some people to benefit but for those who can make it work, significantly lower costs and better quality of life will likely be the rule rather than the exception.  The silver line around the gathering squall is that SDS will appeal to many who have been leery of it.  First chance we get, though, those eligibility criteria should be revisited and relaxed.

5.  Be kind to the grouchy, negative, critical and portly.

Best wishes to all of you in the new year.

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.

Inclined to agree

When meeting the obligations of the community-based system is projected to cost more than the budget allocated, the Department of Developmental Service (DDS) is required to file a "deficiency request" with the legislature to request an appropriate additional amount. In January, DDS submitted such a request for the current year.

Senator Dennis Hollingsworth, a member of the Senate subcommittee to which DDS' request was presented sent a letter to the rest of the subcommittee stating his opposition to roughly two thirds of the request because it was not accompanied by any attempt at reform.

I don't know if Senator Hollingsworth and I would agree on what reform means, but I agree with him that this system has proven we will not spend our way to excellence. That war is lost whether we continue to have battles or not. If the community won't fight for reform with the same vigor that we've fought for money, the "reform" will be a familiar, unconstructive, unproductive, inefficient, damaging, depressing and/or diabolical one like the Purchase of Service Sandards of the past which will damage the lives of indivuals without saving money. Better to ask for a leaner, more person-centered support system focused on adding value to the lives of people with disabilities with less regard for the institutions involved.

We can win that war, if we'll fight it, because excellence, unlike the current system, is sustainable.

Lessons from 2006

Here are some things I learned or had (re)confirmed this year.

1. DDS is so angry at my writing about self-direction that they dropped CADDIS during my vacation to make me look stupid.
2. People with a taste for real change aren't always who you think.
3. System funding is as much an emotional issue for people as it is a practical one, but chocolates and flowers would be cheaper and more helpful.
4. "Efficiency" is a word people love to say and hate to hear.
5. "Accountability" is another.
6. Connecting people is the heart of every important reform.
7. The job of helping people with disabilities to live more fully is still worth doing.
8. The job of changing our system so it helps people with disabilities live more fully is most glorious because it is so unlikely.
9. Some people think living in solitary idleness in your own home is so much better than living with friends in a segregated setting that no one would ever choose the latter even if it came with a large stipend and DSL.
10. Saving the current system and funding it better is an errand for a superior and more committed fool.

Further on the topic of choice

On the topic of choice, I have expressed some opinions. I would like to elaborate on a related issue. In weighing the relative merits of choice and integration, I still remain committed to the idea that choice should trump and that neither the State nor Regional Centers, nor agencies have a compelling enough interest to push integration on those who prefer to live and receive services in a segregated system.

That said, after hearing a very compelling speech just yesterday on the topic, I also agree with two embellishments on that position.

The first additional point is that the boundaries of choice as a policy goal may vary in the advocacy of different people, but these distinctions are philosophical not moral. I may disagree with those who believe the state should differently fund integrated and segregated services in order to support the choice of integrated services, but I do so on practical grounds and with no truer compassion or greater honesty than those who take the opposite position. To the extent that state, regional center or agencies believe they have a compelling interest in limiting choice to a more integrated environment, it is appropriate for those entities to better support integrated services than segregated ones.

The second additional point I'll confess is that I agree absolutely with value-based funding as an improvement on the collossally irrational system we have now. I also agree that the supports necessary to sustain people with developmental disabilities in integrated lives are more valuable than those that support the same individual in a segregated setting, given that the former is harder to accomplish. If integrated services were to receive biased funding in their favor on the basis of value rather than cost, I could support such a policy.

OK, satisfied, J? And I posted in November, too.