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.

Leadership

One of the perpetual issues in the system is that of leadership development and the good friend who scolds me behind the scenes when I go long between posts has this issue often on his mind.  So, good friend, here is a post in which we can discuss leadership.  

Leadership is one of those things we mostly all yearn for but, like other nearly-universal human hungers, we may disagree on what kind of monkey we want to be satisfied by.  In a system in which power, control and sovereignty are the largest common currency, leadership generally may even be dangerous.  I suspect some would say we don't produce enough leaders to meet demand and Tom Pomerantz' touring schedule supports that position.  Others argue that we are producing plenty of leaders in the form of plain-spoken clients and uncomfortably empowered family members (cf. Stanley) but that these leaders are A) Too locally focused and personally interested to lead in harmony; B) Not listened to; and/or C) adorable but hardly authoritative.

If you all are waiting for me to say something smart about leadership, that had also been my hope but I think I'd best turn the floor over.  Here are some questions:

1.  Do we need more leaders?

2.  Can we develop leaders without indoctrinating them?  And if not is it leadership we're developing?

3.  Do you agree with Voltaire who is often quoted saying he would rather obey one lion than 200 rats?

4.  If herding cats is the paragon of leadership in chaos, what is being herded by a herd of cats the paragon of?

Two bills.

There are two bills we are supposed to be talking about, AB 2424 (Beall) and AB 1192 (Evans.)  Both seem simultaneously well-intended and not helpful but I'm open to having explained to me why the bills are either diabolical or useful.

To summarize briefly, AB 2424 is a wide-ranging 30+ page concoction meant to implement for especially transition-age children with developmental disabilities some of the recommendations of the SB 1270 hearings. Long legislation makes my head swim a little and I definitely need a second or seventh reading but one thing jumps out at me immediately: The law puts a lot of mandates on regional centers to, for instance, do timely IPPs and to have a bias towards work in an integrated setting. We've discussed before here whether or not that bias is appropriate but what is troubling me is that there are already IPP-related mandates that are complied with, if not never, within the statistical margin of error of never. Fair Hearing rights would be one example.  

Until there is some evidence that the legislature controls the executive branch and DDS can and does require compliance with regulations from regional centers, any legislative input into the IPP process seems either pointless or cruel.  To put in the funding contract language requiring compliance is entirely pointless without monitoring and enforcement, which is why no DDS client has ever (with a confidence interval of p=95%) heard of their fair hearing rights unless they were themselves intrepid researchers or were assisted by a wise parent or craven vendor.

AB 1192, which I have also heard referred to as AB 1983 (maybe a pet name) is similarly clearly well-meant and otherwise baffling.  This bill will require establishment of an abuse registry, require that service providers consult said registry and forbid service providers from hiring people listed.  Like the pursuit of integrated employment opportunities, the rationale is unassailable.  I imagine every other ED, like me, loses more sleep over the prospect of employing an abuser than over funding which is otherwise everything we love.  What I can't figure out is the value of the registry.  It seems to me that if a person has been convicted of a crime including abuse, that conviction should appear on the criminal background check we are already required to do.  If a person has not been convicted of a crime, it seems abusive and, perhaps, unconstitutional to prevent that person from working on the basis of a crime they have not been tried for and found guilty.

So, I guess there are two points we can discuss here.  The first is: What don't I get about these bills?  Is there a reason to support them other than their intent?  The second is whether it is harmless to pass harmless legislation or whether such legislation causes damage as a distraction from important advocacy that otherwise might be done.  

Brer Stanley, I know you have in the past expressed enthusiasm for 2424.  Educate me, please.

Whose quality?

Inspired by Brer Stanley, our new topic for debate is about quality.  Quality is something we all agree is important and then, by and large, ignore.  People who have read this blog in the past know that the opinion here is that the single most important reform we could make to our system is ongoing evaluation of the quality of programs, regional centers and policies on the basis of outcomes.  Here's the tricky part:  We just debated whether choice is or is not more important than integration.  If it is, there's a challenge to the measurement of quality.  It is very hard to standardize the evaluation of choice because standard measures need to be valid , meaning that the metric must measure what is designed to measure and be counted the same way by different surveyors.  So the challenge will be developing valid metrics to gather statewide while honoring choice.

One model, the one used by HSRI, for instance, I think, is fairly strong on validity but weak on choice.  Even if you evaluate based on whether a client reports being given a choice, if every other metric assumes the state's preferred outcome and rewards for it, the pressure is to treat all people with developmental disabilities as if their most intimate decisions are to be pleasing to the people at the Bateson Building in Sacramento.  

The common alternative model, I think of it as the JN or LQA model, is to have a deeply considerate and subjective evaluation so cumbersome it typically sits on someone's shelf unimplemented.  

A typical Life Quality Assessment was kind of silly because it was so subjective that which day of the week a client was interviewed could alter the entire result.  A more valid survey biases every professional in a client's life toward state policy and away from the person served.

So, the question to you all is: Is it better to employ a highly valid system that might counteract client choice or is it better to use a subjective system which honors choice at the expense of usefulness or is there a better or more balanced solution?

The Great Debate: Congregate?

An issue that comes up often in backrooms and private conversations but rarely in open policy discussions is whether the State should establish a preference for non-congregate supports as matter of law.  The discussion we just had was so much fun, and thanks to all who participated, that I would like to see if we can't continue discussion.  I'll play a similar role to the one I played on the 22nd, where I'll introduce my understanding of the two sides in the discussion and ask skeptical questions of the people who leave comments.  As before, you are welcome to be as anonymous as you like, but please choose some form of address so that if people want to take up your points and support or challenge you, they can make clear to whom they are referring.

101:  There are, as there should be, many ways that people with developmental disabilities are served.  A distinction can be and is drawn between "congregate" support and "community-based" support.  "Congregate" support is often delivered in a licensed facility ordained to the purpose of assisting people with disabilities, most often with paid staff who, at any given time, are responsible for more than one supported person.  "Community-based" support is generally delivered in places not otherwise dedicated to people with disabilities in particular and there is typically one or more paid staff-person assigned to concern themselves with each supported person.  Exceptions to the preceding are probably rife, but I think that will do for the needs of a blog.  Common examples of congregate services are residential facilities where people with disabilities live under supervision and day activities designed to occupy the supported person's  time away from home constructively.  Common examples of community-based services are wrap-around individualized services intended to secure individuals in homes and lives with maximal sovereignty and liberty.  There are few, if any, voices arguing that more congregate care is our best future and it is almost as rare to hear anyone argue that tomorrow all the congregate care in the State should be shuttered.  So the argument is generally whether incremental and intentional shifts toward community-based care should be centrally directed or whether the state should remain neutral on the mix of services employed.

The Proposition:  The State of California should change statute and promulgate policies in order to prefer community-based services for supported individuals to congregate services.

Introduction and an observation:  In all likelihood, there would be no debate, the hopelessly contrary excepted, that people with disabilities should be safe and well, pursuing goals of their choosing and fully integrated into the community.  Taken together, those three aspirations: Safety, choice and integration are always supported.  In the practice of people living lives, those three virtues are often in conflict with each other and different people resolve those conflicts differently.  In his first letter to the church in Corinth,  Paul wrote of three virtues: faith, hope and charity, stating that of the three charity was the greatest.  I would contend that this debate is really a dispute over whether safety, choice or integration is the equivalent of Paul's charity in the scriptures of California Welfare and Institutions Code, Title XVII. 

OK, so here are my top five pros and cons to the proposition above:

PRO:

1. While congregate services may be of great value to the individuals served, they do not fundamentally change society's view of people with disabilities.  Only the presence of people with disabilities in full view of and participation in society will change how those unaffected by disability see their neighbors.

2. Efficiency is a subtler thing than people like to claim.  If community-based services cost twice what congregate services do "per unit" but deliver thrice the satisfaction, freedom and social value, then community-based services are more efficient, not less.

3. As the costs of legal liabilities and risks grow, models of support in which the State and its agents have less direct responsibility for the safety of the individuals served grow less costly compared to site-based care.  As quickly as the cost of staffing, the main component of individualized support, has grown, the price of insuring facilities may grow much faster.

4. None of us are free as long as one of us has their toothpaste chosen for them.

5. People with "developmental disabilities" have adapted and grown with support much more quickly and easily than the support itself.  For the state to remain neutral on the evolution of the system is actually to be biased toward older models.

CON:

1.  Policy makers can not dictate the values of the individuals served.

2. Whatever models of support may compete in the marketplace, choice is always more efficient than policy-making.  Those who provide wrap-around individualized support know how much money, time and effort gets wasted replacing jobs for people who intentionally and cheerfully engineer their own firings.

3. There is a subset of people served by this system whose medical and emotional needs are unmanageable without support and who would be spectacularly expensive to help if their needs weren't served together with others.  If we're honest about the resources available to us, such as specialized nurses, there is probably a subset of people it would be impossible to serve except in a congregate setting.

4. As an 18-year-old girl I was trying to help find integrated activities once told me.  "I don't like normal people.  Don't you have a group with people like me I can join?"  As a 55-year-old woman I was trying to help find a generic job told me, "Stop treating me like I'm normal.  I'm not normal."  What no policy maker, program director or advocate can do is go back in time and undo the message some people with disabilities have taken to heart they belong to a separate group.  To ask frightened individuals with disabilities to bear a special cost for our joined past is unfair.

5. The Lanterman Act itself does not divide history. The institutional mode of "support" was an expensive failure. The fact that residential facilities and day programs were created under the Lanterman Act as community-based alternatives does not mean they don't replicate the model. The trend of history is the fading of institutions and the rise of the individual.  200,000 people increasingly unaccustomed to segregation can decrease the prevalence of congregated care on their own while the State maintains it's integrity by not choosing between choice and integration.

OK, friends:  Whatcha got?