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.)

Questions

Marty Omoto reported today that the Department of Developmental Services will publish its process for identifying cuts. That's a good thing, although the coincident report that the new trailer bill language will be available next week suggests it won't be much of a process. I'm left wondering if DDS, which has now had two years of near certainty that further cuts were coming to think about this. I'm curious whether they will seek to reduce costs generally or in a targetted way. In other words, machete in the daytime or grapefruit spoon in the dark?

About the Examiner

So, I thought I would begin the new dealybob at Examiner.com with an explanation of what I would write as a reference for any future readers who would happen by. That first post was rejected, probably appropriately, for being too much in the first person. But, just to share, here is what it would have said.

***

Welcome,

This will be my first article as an Examiner (and so, the oldest one in my eventual archive.) It's a good place to predict what this column will cover. Consider this half a promise and half a bet, if there are takers for either.

This column will cover events, trends and policies related to the provision of human and social services. Professional caregiving is often publicly funded and usually highly-regulated so public policy will be discussed extensively, but market forces and demographics will also be considered. Sporadically, we in the social services think about actual people, so expect occasional profiles of people with disabilities, policy-makers, caregivers, charlatans and reprobates.

About me: I work in the social services industry as the chief executive of a small for-profit company that assists adults with developmental disabilities to live independently, as a subcontractor to state contractors. We will soon offer companion services to the elderly and physically disabled.

There is a phrase in the paragraph just above to make anyone skeptical, so here are the biases I'll admit to up front-

1. There are two principle purposes for having a social and human services system, to defend the threatened and to extend community participation beyond the barriers that nature and circumstance impose.
2. Services provided through government tend to be both inefficient and underfunded for their missions. The former defect makes a bigger difference than the latter and is more fixable. Inefficient service delivery creates costs not only to the taxpayer but also to the people who depend on the support provided, through malarkey.
3. Purely private services may (or may not) be more efficient, reliable and of higher quality but are also extremely rare. Very few of us will ever receive professional care not influenced by public policy.
4. Ideology drives idiots crazy, madmen to folly and reasonable people to fake deafness. This column will be very interested in the granular details of what works and doesn't work in both regulation and the marketplace. Democrats, Republicans, vampires of both union and capitalist varieties, dithering managers and doddering staff all may receive attention here, some of which may be complimentary.
5. I am a reformer, may heaven have pity and my neighbors patience.

Sounds fun, right? I welcome your comments.

Brand new bag

Howdy and a quick announcement. I am now writing generally about social services, human services and professional caregiving for Examiner.com. It's something slightly closer to a job than this blog has been. The new site will take most of the effort I've been putting into this site (roughly 1400%) and be less focussed on developmental disabilities. I'll keep this site so Andy and Stanley have somewhere to rant and I can get deep in the policy weeds from time. The link to my new page is in the title of this post.

You're all welcome to join the conversation there.

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?

The pettiest post on this site

This is a very small point, but the conversation around caseload ratios for service coordinators has become too funny to leave be. What I keep hearing is that for HCBS waiver clients, the caseload ratio remains limited to 62:1 but that the cap has been lifted entirely for non-waiver clients. It makes sense that people would say this because neither CMS nor DDS nor anyone else want California to twit the federal government in a way that requires a response.

But, the assertion keeps getting made without irony or humor or apparent self-awareness so let's just us, we few who discuss here, set the record straight. If the non-waiver caseload is uncapped, then the waiver caseload is also uncapped. The reason I think so: I don't know of a regional center that has waiver and non-waiver caseloads. As far as I know, all service coordinators have mixed caseloads.

This means that that to say "we have a 75:1 caseload ratio" means the same distribution as to say "we have a 62:1 caseload ratio for HCBS clients and a 101:1 ratio for non-waiver clients (assuming 2/3 of clients are on the waiver and I did my math right.) Really, this is a very unimportant point, but I do hope you will join me in smirking whenever you hear someone claim that the caseloads are fixed for waiver clients.

Other closures

Much has been made of the pending closure of Lanterman Developmental Center, and it would be to our detriment to ignore the impact of the planned closure of Lanterman Regional Center. According to DDS Director, Teri Delgadillo, Lanterman is being closed and merged with Harbor and Westside regional centers to save money. As Ms. Delgadillo says in her statement, "The administration considers these three regional centers, which have already harmonized their service coordination process to the degree that client expectations have been regionalized. Furthermore, by pooling staff, the combined regional center will have the capacity to say 'no' in more than 80 languages."

"We certainly defer," Director Delgadillo continued, "to the combined 80-person board of the merged center in terms of naming the new facility and appointing management. But DDS personnel are recommending 'Richard Riordan Regional Center,' because we enjoy the sense of whimsy that alliteration brings."

Walt Disney Regional Center, which will be created from the merger of South Central and Orange Country RCs will have the capacity to say "please" and "thank you" in more than 30 languages and on legal pleadings.