So, now that POSS standards have been so thoroughly discredited that they probably won't re-emerge as a proposal until August, it seems like this window can be used to discuss meaningful reform which might meet one-or-both criteria of improving the lives of people with developmental disabilities and improving the taxpayer's return on their investment.
The biggest omission in California's system is a meaningful, useful (or even non-fictional) system of evaluation and accountability. In human-service systems around the world, governmental or private it is standard practice to measure outcomes. In other words, since we know why we do this work its worth asking if we're succeeding and how well. Measuring outcomes, when done correctly, can establish causal relationships between the work that is paid for and the results which are obtained. The system, the people the system serves, service providers and the state's taxpayers can all benefit by:
-Making available objective information about which agencies and programs may best serve an individual;
-Allowing for informed budgeting so that more money goes where it helps and less where it doesn't;
-Improving advocacy by allowing consituencies to demonstrate what is lost when funds are unavailable; and
-Providing a basis for all system stakeholders to recognize what works, what doesn't and how to improve.
-Plus, one Director of a small ILS agency will sleep better at night, providing for better management of that agency and less crankiness at meetings.
Although California's state government hasn't done much to make evaluation happen, that isn't because a lot of smart people haven't put good thinking to the task. Julie Jackson, Deputy Director at California's Department of Developmental Services has thought about, worked on and advocated for evaluating services systemwide. Dr. Barbara Wheeler at USC/UAP has worked on devising an evaluation model which fully integrates the concept of choice into outcome measurement (this work is ongoing due to the distraction and unreliability of a colleague of hers who nonetheless found the time to start a blog.) California Community Action Network (the predecessor to CDCAN, mentioned below) has often focused attention on the need for outcomes for those who receive services. A national Core Indicators Project is years underway and the Service Delivery Reform committee which met a few years back picked some domains and agreed to set-up a learning model of evaluation as long as there was nothing complicated about it. Assemblymember Keith Richman (R-Northridge) included a first step toward evaluation in a bill he sponsored (AB 2775)this session which is being held in committee.
So why is there no real evaluation or useful accountability in the system? One problem we're up against is the difficulty of making long-term investment during a budget crisis (can you call it a crisis in it's fourth year?) I suspect another is that during the Davis Administration, the state Department of Finance fell in love with the idea of standardizing and set that agenda. Schwarzenegger's DOF is carrying the same torch. Yet another challenge is that service providers, who have tended to be the organizers of much of the system's advocacy tend to feel pretty strongly that measuring the result of their work is a poor substitute for funding it better. Hopefully, if real organizing continues at the grassroots level, the people who deserve the best possible system will focus more on their need for support that really helps than the historic concentration on provider rates.
Mind you, doing evaluation correctly or even well takes a lot of work. One old saw is, "What gets measured gets improved" and it can be challenging to make sure you actually measure the things you want to improve rather than the things you wish to avoid. In my experience, Unicorns are rarer than well-designed evaluation systems which are rarer than trout. In the case of California's system of support for people with developmental disabilities you can reverse the first two terms.
Later posts will discuss some thinking about what would make an evaluation system useful and meaningful to this system.
Monday, July 26, 2004
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.
Monday, June 28, 2004
Why call for system reform?
There are really two perspectives that call for reform. The most important is the sense of frustration often heard from people with developmental disabilities and their families that, in spite of California law, services don't fit. While nothing can be said of California's system uniformly, it is often said that the system continues to favor a few basic service configurations over innovative, individualized ones. Recent policies at some Regional Centers which refuse community-based day programs to clients because these are difficult to administrate confirm that institutional obstacles continue to frustrate the full implementation of the Lanterman Act.
A second, less important but more imposing political compulsion is the cost of the system. Defenders argue, I believe rightly, that the system seems costly only in the absence of verifiable accounting for the cost-savings the system also brings by deflecting people with disabilities from more costly care needs. When we consider the system's success in drawing down federal funds, private fundraising and add to that the unknown cost of care without our system in place, we offer a good deal to the state.
Be that as it may, the cost of this system grew significantly faster over the 20 years to 2002 than the economy of California, the resource which must be tapped to sustain us. Over those twenty years, that gap has been steadily accelerating. In the end, sustainability can't be measured against theoretical savings but only against available resources. Those who seek cost-saving reforms have a point, that the current system is unsustainable in the long-term.
What's more, the failure over the thirty-plus years of California's community-based system to measure and account for the outcomes provided is the reason we cannot reliably take credit for the savings achieved.
If the story ended there, I wouldn't have started this page. The mother of a 36-year-old with autism made the comment to me not long ago that we were all so busy fighting budget cuts that "we haven't even started fighting the right war yet." That battle will be for a system which fulfills the promise to accountably recognize the differences between people and fully implements the right plan for each. I believe we'll continue to fight the wrong war until we fight the right one. Many groups across the state are doing this, but many of the fiercest and most articulate advocates remain focused on funding the current system.
The accountable system, the truly individualized one can provide more to people with disabilities, save more from the state budget and account for the value it delivers. Starting next week, this blog will begin to discuss specific reform proposals. The underlying theory will be that the right war is the only one we can win.
A second, less important but more imposing political compulsion is the cost of the system. Defenders argue, I believe rightly, that the system seems costly only in the absence of verifiable accounting for the cost-savings the system also brings by deflecting people with disabilities from more costly care needs. When we consider the system's success in drawing down federal funds, private fundraising and add to that the unknown cost of care without our system in place, we offer a good deal to the state.
Be that as it may, the cost of this system grew significantly faster over the 20 years to 2002 than the economy of California, the resource which must be tapped to sustain us. Over those twenty years, that gap has been steadily accelerating. In the end, sustainability can't be measured against theoretical savings but only against available resources. Those who seek cost-saving reforms have a point, that the current system is unsustainable in the long-term.
What's more, the failure over the thirty-plus years of California's community-based system to measure and account for the outcomes provided is the reason we cannot reliably take credit for the savings achieved.
If the story ended there, I wouldn't have started this page. The mother of a 36-year-old with autism made the comment to me not long ago that we were all so busy fighting budget cuts that "we haven't even started fighting the right war yet." That battle will be for a system which fulfills the promise to accountably recognize the differences between people and fully implements the right plan for each. I believe we'll continue to fight the wrong war until we fight the right one. Many groups across the state are doing this, but many of the fiercest and most articulate advocates remain focused on funding the current system.
The accountable system, the truly individualized one can provide more to people with disabilities, save more from the state budget and account for the value it delivers. Starting next week, this blog will begin to discuss specific reform proposals. The underlying theory will be that the right war is the only one we can win.
Tuesday, June 22, 2004
California Disability Community Action Network
First things first. CDCAN is the most innovative political instrument I'm aware of. It's role is to inform and organize, through various media, all interested parties about the political life of California's services and supports to people with various disabilities. Anyone interested in the evolution of our system should be aware of this group.
Please note: The website is currently down so I've cancelled the link. People wanting more information can email Marty Omoto, Director/Organizer at martyomoto@rcip.com
Please note: The website is currently down so I've cancelled the link. People wanting more information can email Marty Omoto, Director/Organizer at martyomoto@rcip.com
Introduction
Hello, friends
This attempt to blog will include information, rumination, analysis and pomposity on the general topic of system reform for California's community-based system of support to people with developmental disabilities. Included will be links to useful websites on the topic, reviews of literature and proposals and proposals of proposals. I have no doubt that this will be as stimulating to everyone as it is to me. My goal will be to include an update not less than weekly.
My perspective on this topic is based on who I am and which airs I put on. I am the director of an Independent Living Skills agency. I am the uncle of a beautiful 4-year-old with disabilities. I am a reformer, may God have mercy on me.
MILLENNIUM, n. The period of a thousand years when the lid is to be screwed down, with all reformers on the under side. -Ambrose Bierce
My basic assumptions about this system are:
1. All people have the rights enumerated in our constitution including personal sovereignty which is not waived by receiving public benefits. Californians with disabilities are rightly entitled by law to support based on their personal challenges which does not interfere with their aspirations.
2. All people should expect their taxes to be handled dearly, used efficiently and to serve only ends endorsed through the constitutional process of government. Healthy systems are cost-effective and cost-effective systems are healthy, and no system without deliberate and rational accountability is healthy or cost-effective.
3. All state-funded systems ever and California's system of community-based support for people with developmental disabilities, especially, have plenty of opportunity to improve regarding the first two assumptions.
OK, so, let's see how this goes.
This attempt to blog will include information, rumination, analysis and pomposity on the general topic of system reform for California's community-based system of support to people with developmental disabilities. Included will be links to useful websites on the topic, reviews of literature and proposals and proposals of proposals. I have no doubt that this will be as stimulating to everyone as it is to me. My goal will be to include an update not less than weekly.
My perspective on this topic is based on who I am and which airs I put on. I am the director of an Independent Living Skills agency. I am the uncle of a beautiful 4-year-old with disabilities. I am a reformer, may God have mercy on me.
MILLENNIUM, n. The period of a thousand years when the lid is to be screwed down, with all reformers on the under side. -Ambrose Bierce
My basic assumptions about this system are:
1. All people have the rights enumerated in our constitution including personal sovereignty which is not waived by receiving public benefits. Californians with disabilities are rightly entitled by law to support based on their personal challenges which does not interfere with their aspirations.
2. All people should expect their taxes to be handled dearly, used efficiently and to serve only ends endorsed through the constitutional process of government. Healthy systems are cost-effective and cost-effective systems are healthy, and no system without deliberate and rational accountability is healthy or cost-effective.
3. All state-funded systems ever and California's system of community-based support for people with developmental disabilities, especially, have plenty of opportunity to improve regarding the first two assumptions.
OK, so, let's see how this goes.
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