ILS/SLS Workgroups

So, this here workgroup thingabob is open enough to have too many participants but not quite open. Since some of us are representing all of us, CDCAN is holding weekly conference calls for what happens in the meetings to come out. Along those lines, I'll post my input to the group here.

Email sent 3/25:

Due to the inspired (yet stern) leadership of Tammy Bachrach, ELARC VAC chair, we spent the bulk of our meeting yesterday divided into tables based on the workgroups. The ILS/SLS group recognized that the legislature has changed their focus from service standards to "best practices," so we allowed ourselves the liberty of focus on cost-saving practices around ILS and SLS. Following are suggestions from the group.

For ILS: It was suggested that we might get more realistic service plans if, when a referral is made for a new ILS client, that in addition to the agencies referred to serve the client, a different ILS agency be referred the task of writing the initial assessment. The suggestion recognizes that when an agency writes its own initial assessment, even the honest and wise among us have a natural bias towards overestimating the need (although probably not by a lot, demagogues.) The assessing agency would have to agree not to work with the assessed client for at least a year.

There are some down-sides to this to be concerned with. One is just that regional centers might prefer agencies that write emaciated service plans. It would be important that the assessing agencies also be serving ILS clients and that the assessor rotate. Also, in areas where there is only one or two ILS providers this arrangement will not be possible. An objection from the group was that the assessment serves an important function of developing a mutual understanding between a new vendor and a new client.

All of that said, I think the idea has merit and should be discussed.

For SLS: There were two suggestions. Unlike the ILS suggestion, these had unanimous support in our discussion group.

1. It was felt that benefit appeals specialist (particularly, but not exclusively regarding IHSS) may be more efficient than some agencies at insuring that IHSS hours are covered by IHSS rather than the regional center or an agency. The proposal is that regional centers cultivate these advocates and vendors that choose this assistance would surrender a portion of their administrative funding proportional to their expected benefit management cost.

2. If somebody could, for heaven's sake, do something about worker's compensation costs for SLS providers, those providers would be thrilled to surrender a like amount of their hourly rate.

Email sent 3/27:

Hi, all. Me again. FIrst, to commend Scott. I think that was a nice job. The only exception I'd take is that some level of skill-development service ought to be available to clients living with family do not intend to change their home setting immediately. Whether that service is provided under the myth of Adaptive Skills Training rather than the myth of Independent Living Skills, makes no difference I can see.

Something that has been on my mind which is related to the topic at least: (The following is written in a prophetic voice, by which I mean I hope to be heard but don't really expect to be listened to, a la Jonah in Ninevah)

A lean system has to be a smart system and our system is never less smart than when it is focused on some sort of reform having to do with vendor codes and categories. Regional Center staff, forced by the nature of the regional center's role to make policy with a minimum of information and a maximum of effect, tend towards involuntary glibness and in my experience lose what concentration and permeability they otherwise retain when the topic of vendor codes is on the table.

Likewise, vendor executives, already prone to priestly grandeur and martyrdom (cf, this email,) are never more divisive, sanctimonious and grasping as when we contest our vendor codes (excepting, of course, when unions sponsor bills.)

To direct care staff and clients, vendor codes represent less than nothing. I don't believe anyone who will be in the room Monday would be able, watching individualized support delivered, to identify the vendor code under which delivery takes place. Either services are led by the client and his or her needs and abilities under the influence of a circle of support or not. If so, the service itself is probably efficient, whether or not the referral process or agency supervision, for example, are. If not, it's wasteful of taxpayer money and negligent of the value clients have the right to expect. I believe that any discussion of reform that focuses on category or code is likewise wasteful of scarce funding and negligent of important support.

So my concern with the work of our group is that it represents a deepening of our reliance on irrelevancies and distractions in defining the value we deliver and setting its price; and steps further away from efficiency and smartness in our system. The legislature has opened an opportunity to be brighter by changing the administration's proposal of "purchase of service standards" to a proposal of "best practices." Granted, that was a bad use of nomenclature but an improvement in focus. I do hope we can take advantage of this. As I said, I don't mean to change the agenda, but I would point out that most of the work we've accomplished so far has been the delivery of data and instructions from DDS and the return of criticism. I don't think much achievement will have been undone if we change our focus.

There is work to be done in how and why clients are assigned for agencies and services, work to be done on how vendors deliver that service. Granted that our services must always be individualized, it isn't necessarily the case that all regional centers and vendors need all of their processes to be idiosyncratic for that purpose. There must be opportunities for service delivery to become leaner which would lead us in a better and smarter direction than a discussion of standard hours or normal eligibility. Since by any name we are really talking about budget cuts, I would hope those cuts could be as much as possible to process rather than to support.

In sincere friendship and admiration (but with a pinch of sarcasm by which old friends recognize me,)

Doug

May God bless and keep you, make his face shine upon you and be gracious unto you. Amen.

Forecast

Alongside "draconian," "savage," "irresponsible," "responsible" and "common sense," "darwinian" is an adjective that deserve to modify the cuts in process. Still, there seems to be little discussion of how the system will evolve in the presence of significantly less funding and new regulations. To the extent that there's a vision for change, it seems to be towards accountability, a welcome new feature, if the new accountability systems proposed didn't seem as spectacularly inefficient as the worst images of the system and if there were some little bit of the new oversight that addressed outcomes.

But as to the composition of the system, I have a very hard time believing that will not change over the next year. What has frustrated me the most watching the changes so far has been the lack of intentionality to it all. In essence, real cuts have come with implementing statute which in at least half the cases was implausible. This has left it to regional centers to cut services not mentioned in the trailer bills. So, from the be the change you seek department, here is my projection for the system we are now creating.

Congregate care will be much more prominent on the menu of options, and large providers will dominate: Larger non-profits, with some notable exceptions such as Jay Nolan Community Services, are principally site-based, secondarily group-based, and often have individualized services attached as tiny portions of the whole. They are also more likely to be non-profit and to fund-raise successfully. These services have been unsuccessfully targeted for cuts. But are the best placed to weather them and have generally avoided implementation of most, leading to cuts not targeted in individualized care.

There will almost certainly be fewer providers in the future. Parent-providers may continue and large agencies should survive but the smaller agencies that comprise most of the individualized system will be less sustainable. These agencies may merge with one another to survive, or close. To the extent that large non-profits are willing and able to provide ILS, SLS, micro-enterprise support or that smaller agencies can merge, person-centered services may continue to be available. But it is worth noting that under the hedgehog principle that firms specialize for a reason, it seems worth noting that at large agencies that provide both congregate and individualized support, ILS and SLS et cetera are usually very small pieces of overall programming.

Note: For the purpose of this post I am not assuming that this is a bad thing for people with disabilities, but I also do not assume this will make care more efficient. While congregated services are cheaper per person and per hour, clients receiving individualized support often require much less of it. I think it would be impossible to say based on data we have whether the site-based system is more or less efficient than its alternative. For example, micro-enterprise and job-coaching are much more common than workshops or enclaves with clients of ILS and SLS services which eliminates a lot of bureaucracy.

Moreover, changes rarely go well without planning and, thus far, DDS has been scrupulous in spreading damage to the system fairly evenly. As a consequence, whatever system change will come is likely to favor not cost-savings nor efficiency, nor quality but the fiscal positions of the providers. Fortunately for everyone, blogging is a low-overhead activity.

In praise of the monkey

I had a recollection this morning of the old system-reform workgroups. The purpose as given was to make changes to the system, in partnership between DDS and other stakeholders, for the purpose of producing more value for the people the system served. All of the conversations, however, wound up focused on making the system more expensive. Better ideas were quickly forgotten in favor of silly ones. More than once since then, I've wondered what it takes to get sincerity and mission from experienced advocates. As much as anything, that question led to my ongoing support for CDCAN.

So, with that in mind, I like the survey monkey DDS employed for ideas regarding purchase of service standards. I'm skeptical that the resulting standards will be any less foolish than much of the existing trailer bill language. Even DDS, which is trying to reduce funding, can't seem to complete a thought on reform without bloating the cost of the system. (I would credit them for paying attention during the system reform.) But at least they are getting input some of which will be candid and thoughtful. I hope DDS continues to solicit feedback broadly and do hereby award them three bananas for current efforts.

A few notes on things as they are

Just a couple quick observations from the hearing 2/10.

First, Ms. Delgadillo used the continuing availability of new vendors in response to a question regarding the affect of existing rate cuts. It bears noting that new vendors receive higher rates than the older vendors that currently have most of the capacity. The number of agencies closing, assuming it is small, might be evidence that rate cuts aren't too damaging but the number of new vendors is entirely irrelevant as a datum.

Second, the audit suggestion depresses me. DDS needs to find ways of lowering the cost of the system other than by raising the cost of the system.

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.