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?

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.

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?

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.

The (Draft) Ten Guiding Principles for the ICBM

At the request of Anonymous, here is the draft I received as the "ten guiding principles for the Individual Choice Bugeting Model Process." (ICBM) I am typing this all in so I expect Anonymous gratitude.

• Reduces overall state General Fund costs.
• Increases fairness, equity, and transparency in the allocation of resources.
• Accounts for geographical cost differences.
• To the extent possible, relies on existing state data systems and assessment processes.
• Accommodates individuals with exceptional or unique care needs and their associated purchase-of-service costs.
• Easy and efficient to administer for consumers, families and regional center personnel.
• Does not jeopardize individual's health, safety and/or well-being.
• Does not impose any unfunded mandates on participants, providers or regional centers.
• Promotes individuals' ability to achieve and maintain living arrangements and work in the least restrictive settings.
• To the extent possible, can be implemented within existing resources.

A few things I would note. First, just to cushion the sarcasm to follow, I'll just say that I don't disagree with anything listed and I don't mean to criticize the author(s) in particular.

With that said, I think it is less important what the principles are than that there are ten. This is clearly a document of good intentions, more than a design plan. It is also worth noting that with a maybe exception for the third principle, these are all principles designed into the traditional system as well. On the one hand, you can consider ICBM a useful attempt to try again. On the other hand, there is nothing in these principles to provide for anyone's optimism.

The last thing I'd point out is that nothing here refers to using unvendored supports, decreasing the involvement of the regional center or either providing relief from or adding to the current, expensive and unimpressively accountable regulatory system. So the pessimists I call my brothers and sisters and inanimate or ungendered kin can rightly justify a jaundiced expectation. If ICBM does constitute some sort of constructive reform, that feature will have been added later.

**Addendum**

A couple of bonus thoughts at no additional charge: One is that the "unfunded mandates" line is interesting given that Counties and IHSS workers are running around buying fingerprint scans willy-nilly and typically at the expense of the provider. I wonder if this line exists in order to specifically lay to rest fears along those lines or whether the author intends it as comforting boilerplate.

Also, the fact that this is a draft of principles and was presented as current in November should maybe suggest to the providers of suspended services to consider other lines of work. If this represents the extent of the work, and it may not, that doesn't promise much in the way of quick development or expeditious deployment.

**Duodendum**

I recently received a note that DDS did not produce the document quoted above and cited below. This might be good news, as we can hope that the actual development process is further along than it seemed and may also be less obvious. The bad news is that most of what I have written in the two posts now seems frivolous and mean. Well, sort of bad and not at all news, but I do repent of the error.

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.

Measuring caps on the Mohs scale.

There are several notorious topics to pick up after my sabbatical from this blog. My favorite format on this blog has been the debate format, so let's start with a discussion of the hard cap on spending which I believe will be on the ballot in May. (Part of the compromise made with Republicans for a fifth of their votes.)  If voters approve the proposition (I'm guessing,) the spending side of the state budget will be limited to current spending plus a growth factor, likely to equal population growth plus inflation.

There's no question a hard cap causes realistic concerns for the future of this system and, more importantly, the people the system serves. But the notion not only attacks the principle of a community digging in to support the needs of their neighbors, it also defends the principle of good government. As with previous debate posts (here and here,) I'll post five arguments for and against a proposition and invite commenters to give their own opinions.

The proposition:  A hard cap on state spending may benefit people supported by California's developmental disability system.

Pro:

1. With the size of government set in the constitution, the focus may move from polarizing and tiresome demagoguery to governance.  The debate I listened to from the Senate Gallery on Wednesday and read in the press was a competition between a philosophy that taxes are the root of all evil and one that government spending is the sole source of earthly virtue.  If the voters set the proper size of government, legislators can turn to subtler and more constructive discussions of priorities and process.  Of course, we'll probably need a whole different set of legislators to grasp the concept.

2.  Under a spending cap regime, voters will have to better interrogate their own values.  As dismal as our legislators have been, their most meritorious action has been to claim to represent their constituents.  In proposition after proposition and election after election, spending whether for water, punishment or people with problems seems to get our rubber stamp.  If the hard cap requires that long imprisonments and prosperous prison guards must be weighed against help for people born challenged, it is entirely possible that we discover ourselves to be a little more Tamino with our neighbors and a little less Night Queen.  A society that chose help for a struggling neighbor over vengeance upon an erring one might be easier for the disabled to integrate into.

3.  A leaner system might produce better outcomes.  Another way our State has failed to choose is between the well-intentioned control-freak and the good-hearted failure.  Regulations build up in our system for good reasons but without any cost-benefit analysis.  Meanwhile, the system does not discriminate between (or identify) functionaries and agencies that are highly productive and those that kindly serve badly.  There are often many people who have to say yes before an individual can be served, or their services can change.  Heaven alone knows how many people are struggling needlessly due to ineffective support.  Hell has the accounting on needless regulatory costs. If this system has to struggle with choices, some of the energy and resources we lose might well be doing mild harm or weak good while stronger support is available

4.  A trade-off between growth and predictability has value.  The cycle has quickened from annual to pretty near monthly in which promises are made, budget crises confessed,promises revoked, outrage erupts and the promises get restated but only partially and decreasingly kept.  It's hard to imagine who benefits from such chaos.  A system in which per-person funding declined slowly and predictably might be better than such a volatile one, even setting aside that the funding outcome might not be worse.  A learning system could probably improve efficiency and keep pace with the declines in capacity if those declines were predictable.  Morever, it is unrealistic to think government can continue to grow sustainably  as a share of society.  

5.  We have more important battles to fight.  This is almost corollary to the point above, but I remember a conversation with the mother of a 40-year-old with autism when her son was about 32. My friend said, at a protest of budget cuts, that we haven't even started the right war yet.  The important struggle has always been making the system work better for those it serves.  At least since I got here in 2000, the urgent one has been funding.  Steven Covey says that what is important but not urgent makes the best use of time.

Con:

1.  Changes in the frequency and severity of developmental disabilities do not track the population and or correlate with inflation.  Duh.  The increasing frequency of autism, for example, had nothing to do with the factors which will ultimately determine the total size of the state budget.  Once a hard cap is enshrined in the constitution, the state will lose flexibility to address important changes.

2.  See #2 of the pro arguments.  We might also discover that as a people we really prefer to persecute our neighbors than to meet them.  In fact, I kinda do.

3.  Competition for state funds favors the many and the well-funded.  Even after clients, families, support staff and people of conscience are totaled up, those who fear crime, want wider roads and/or use marijuana outnumber us.  Teachers, prison guards and ne'er-do-wells are more organized and wealthier.  In an uncapped budget, there are two ways we can grow: by winning an argument with other beneficiaries or one with tax protestors.  Under a hard cap, we can only grow at the expense of another beneficiary.  What's more, other beneficiaries will see us the same way.

4.  There is no reason to think our system will get smarter as it gets leaner.  The record so far: We cut less costly and more integrated service modalities more aggressively than more expensive and segregated ones.  We cut low-cost providers proportionally with more expensive providers of the same service.  Most new regulations are written for the purpose of containing cost and avoiding risk, not to make services more efficient or integrative.  The best and smartest advocates our system has had in the legislature haven't succeeded in making positive reforms.  Nothing has been accomplished in my time here to make the market mechanisms in the system work to allow useful accountability, transparency or information to clients or family members.  A cheap dumb system is unlikely to function as well as a prosperous dumb system.

5.  Are self-directed services rolled out yet?  Right.  SDS in many ways represents a miniature of  the best we could hope for from a capped state government and three gubernatorial terms have not brought it to statewide reality.  Unpromising.

OK, y'all's turn.

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.

Self-Directed Services (SDS) Regulations, an update.

The Community Services and Supports Branch of DDS held the second of a string of meetings with various specific stakeholders on Tuesday in Sacramento. There is to be a general stakeholder meeting on October 25 in Sacramento and a series of three teleconferences before the proposed regulations are filed with the Office Administrative Law which is planned for the dawn of the new year.

The first thing to be brought up in any discussion of SDS is the fact that it is currently linked in statute to the computer system CADDIS coming online. What has passed for progress with CADDIS is that in 2001-2004 DDS pushed back the "live" date by one year annually and in 2005 they pushed it back by a month every 30 days. They are backing up by a year, maybe, three times per annum so the true process for implementation of SDS almost certainly looks like this:

January, 2007 the regulations are to be filed with the Office of Administrative Law for a one-year process of acceptance.
January or, maybe, April 2008 the regulations are enrolled.

May, 2008, the live date for CADDIS is estimated to be March, 2010 and trailer bill language is sought to alter the statute so that SDS can be implemented following changes to the current data system and the roll-out date for SDS becomes January 1, 2009.

Summer, 2018 the necessary changes to the current SANDIS data system are completed and an entirely different set of regulations take effect.

All of that said, I can offer a few impressions of the current state of the regulations.

First, the budget setting methodology has been fairly well articulated. I'm not mammothly impressed by the statistical methodology on the surface but in fairness, I have no idea what was tried and how it worked. A demonstration of the methods and charts of the underlying data might lead to the conclusion that the methods were wholesome and fair or offer the community at large a means to improve them, apart from our instinct to just make everything more expensive where possible.

Notably, DDS has separated durable medical and environmental adaptations from the initial budget calculation to allow people who need long-lasting equipment to purchase that without fear of depleting the budget for ongoing needs. That was a smart and positive change. Unless such expenses are with-held from the calculated averages that make up one of the available budget methodologies, the cost-savings from SDS might be diminished and cost-savings will be important toward sustaining SDS.

Also, the readiness of the regulations was not what I might expect from something two months from filing. There seemed to be a lot of discussion points and items DDS seemed ready to reconsider. This suggests one of two things:

Either the meeting was something of a placebo with sincere intention to make improvements but also the willingness to make notes in the draft at more points than staff was willing to alter; or

There is no right version where the community will be happy and changes will continue to be suggested until we are all dead, which would suggest the previous possibility as the smartest strategy.

In either case, there are two new areas where I would have concerns somewhat more compelling than my usual flippancy:

1. In the eligibility requirements there was a disagreement between staff and some of the attendees whether or not the requirements in the regulations were more restrictive than in the underlying statute. As a historical note: During the discussions convened by Senate staff, the original DDS proposed statutory language contained this: that the eligibility criteria include, but not limited to. The Senate staff made clear that the "but not limited to" would be dropped in the statute and it was. The history is important because it makes clear that DDS was not meant to be empowered with the right to tighten the the eligibility criteria. For this reason, I think it is only appropriate, as long as there is controversy about the meaning of the regulatory language, to use the statutory language verbatim in that section. It will, after all, be the interpretation of the individual regional centers, not the intent of DDS which govern the implementation of regulations in nearly every case.

2. The "accountability system" as it is currently constructed seems to be as fraudulent as the one we now "use." In the current draft of regulations it will be the responsibility of the SDS client to submit an evaluation of vendors, which would be a wonderful thing to do if and only if the requirement to evaluate is enforced, something the current regulations offer no mechanism for, and the evaluations are aggregated and easily obtained, something else the current regulations offer no mechanism for. I would strongly urge DDS, if the authority exists in statute, to provide for a useful reporting system on quality. Granted, one of the virtues of SDS is the ease with which individuals can fire unhelpful supports, but a far more helpful method of improving quality would be to allow SDS participants some method for identifying those providers most apt to provide helpful support. If that cannot be done under existing authorities this requirement ought to be struck as a useless intrusion on the client's time.

Related to this second point, there are some elements, SIR reporting by unvendored providers comes to mind, that seem unenforceably mandated. Unenforceable mandates tick me off.

Two where the regulations seemed surprisingly strong:

A. The budget allocation process is magnificently transparent and predictable which will make it easy for potential participants to judge whether or not they will be well-served by SDS and which method to choose. There can't be three other sections in Title XVII as well-designed. That said, and as noted above, the right method for developing the actual funding attached to the process will make the difference between SDS being popular or almost unuseable.

B. The descriptions of the Financial Management Service, the role of regional center personnel, and the assignments of service providers are less overdefined than I expected them to be, compelling me to partially and semi-sincerely apologize for my previous post. In my opinion, DDS still erred on the side of over-regulating but not by as much as I was prepared to rant against.

On a whole separate note, I wish to grouse that those who pressed for eligibility criteria to exclude people receiving services in congregate settings will regret that decision a year or two after SDS rolls out, should they be blessed with world enough and time. I still believe that the effect will be to minimize community integration as a byproduct of the new system. That error being now enshrined in law, there isn't much to be done about that but whine, as I do here.

Self-Direction, Finale (for now)

To those who have noticed and inquired and thank you to those that have, I thought I'd wait until the new self-directed services regulations come out and then fume about how prescriptive they are and how they over-regulate while under-protecting the enrollees. I thought the new regulations would be out by now. That much I was wrong about.

Organic farming and row crops.

In some ways, the DDS system is the future of effective government, depending on entitled rights and an engaged private sector to serve the needs of a challenged population. The mission of the whole edifice is to sprawl, broad and variable enough that each person served can find their own access point to the help they need for their challenges and aspirations. An organic approach like this parallels innovations in the business world where individualization has proven more efficient in many scenarios than the standardization that the industrial revolution brought and maintained.

The culture of government, however, has trouble with risk and risk is synonymous with variation. So, having envisioned an ecology of support, the organs of government soon fall back to establish control and order. Instead of encouraging relatively unfettered innovation, the regulations develop over time to specify the types of service available and to constrain the freedom of the service providers, rather than specifying outcomes and allowing competing and co-existing models for delivering such. For example, if you compare the older regulations governing Independent Living Services with those governing Supported Living Services, their are significantly more barriers established in the latter. Consequently, individuals who would be classic supported living clients may receive Independent Living Services instead as a result of, perhaps, economic or health risks which result in sometimes leaving apartments to stay long-term with family.

Over time, the instinct at regional centers has often been to harden and sharpen the distinctions. For example, to deny any individualized living support or training to individuals who live with their families or in group homes, which often has the effect of limiting people to their current setting. The consequence has tended to be to regiment the people served rather than to liberate them.

Why transparency matters

Transparency may be the most underappreciated feature of a strong system. Every day system stakeholders experience the ability of bureaucrats throughout the system to stretch the letter and spirit of existing statute and regulation. Often, those innovations are flexible solutions to situations not foreseen in the development of existing law. Often the experience is of a misrepresented regulation for the purpose of saying no to a flexible or compulsory solution.

The more that DDS, Regional Center and Vendor actions are exposed to sunshine, the more likely flexible solutions will be applauded and inappropriate denials of rights will cost the decision-maker. At every level of the system from the legislature to the quality of breakfast in a group-home, people with disabilities benefit from the various agencies understanding that the quality of their work being widely known and understood.

I offer an additional point, my own theory. I do believe that control must be balanced with the organic process of policy-making. Because most decisions are made in the dark by people alone, each of whom most often prefer to be in control, I expect that the system of support for people with disabilities is massively out of balance on the side of rigidity. An open dialogue can massage that stiffness and restore some of the flexibility the developmental disability system in particular was wisely designed for.

The CDCAN initiative to enable journalism by system stakeholders is so important. The fact that anyone's actions may be the subject of a webcast marks a major change to the milieu in which professionals act regarding disability rights and opportunities. Along with the teleconferences which highlight the micro-effects of macro-policy, CDCAN is the largest part of a systemwide push for greater transparency and through that, greater accountability and better decision-making.

CDCAN is not intended to be, nor should it be the only agency expanding transparency. At the local level support groups, boards of directors, blogs (God help us,) and other networks have the opportunity to make transparent local and even individual policy-making and action.

A note about client and worker confidentiality. The right of the individuals involved in this system impedes transparency but also represents a crucial element of the dignity of the individual. Efforts to increase informal information-sharing and public awareness of what actually happens in the system need to consider the importance of privacy and privacy-protecting law. That said, two principles should be remembered: The freedom of the press is enumerated in the constitution and, therefore, no law or regulation can impede the right of people to seek information regarding public decision-making and to publicize the information obtained is superior to every confidentiality provision on the books. Second, confidentiality is the property of the person the decision regards, not the professionals participating. There is unlikely to be a legal offense where a person wants their story told.

Update: Chris Thompson has left a link to a site he writes with a partner on transparency as a communication tool. Click here to read about why transparency matters.

Policy and Politics

So, it's the day after election day and it seems like a time to talk about the importance of policy in our political process. I've been assured by smart political people that policy never moves politics, that politics move policy (or immobilize it.) The day after yesterday I'm just not willing to tolerate that outlook, never mind the truth of it.

The question is always how much money is enough and that is the political question. Most observers of this system not only question whether it is delivering it's promise, many question whether it's even delivering $2 billion worth of that promise. It is through the insitutions set up to deliver services that the money either becomes appropriate support or not. Those institutions largely follow policies which may or may not be working. The system is a process of turning the money the State delivers into support and if the process isn't working, then change is needed. That change will be in the policy not the broader issue of funding.

I find myself uncertain about what I believe right now. It's a bad day to carry a passion for good government. What I feel sure of, though, is that good institutions bring out the best in people and bad ones the worst (that's a quote, I'm just not sure whose.) My faith is shaken today, but in the end things only get better through better institutions and in our expansive society, institutions increasingly are increasingly manufactured from people and policy, not stone.