Category Archives: human services

The Friday Afternoon Newsdump of the Year

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Gee, what a co-inky-dink. A new report on the rumblin’, stumblin’, fumblin’ rollout of Vermont Health Connect was released on Friday afternoon. 

Before Labor Day weekend. 

When Governor Shumlin was hundreds of miles away, at his vacation home in Nova Scotia. 

Ah, leadership. 

The report is pretty damning, and should have been tackled head-on by the Governor instead of being shuffled quietly out the door on a holiday weekend. It’s not too late; he could come back to work, express dismay at the report’s conclusions, take repsonsibility for administrative failures, promise to learn lessons and do better in the future, and maybe even fire a few people. 

Now, that would be leadership. And it would allow the Governor to launch his re-election campaign next Monday in a strong, purposeful, and accountable manner. Do I think that will happen? Eh, probably not. But it’d be nice. 

The report was written by Optum, the consulting firm that’s trying to fix the mess left behind by former contractor CGI. Topline, per VTDigger: 

A lack of leadership at Vermont Health Connect left the tech firm CGI unaccountable for work it was supposed to complete on the state’s health care exchange, according to a consultant’s report released Friday.

 

The state “ceded” responsibility for the project’s success to CGI, …and as a result, “CGI has not met its commitments.”

This is bad. This is not a technology issue in a super-complicated new system, as the Administration has insisted; it’s a failure of management on the part of Administration officials who should have been riding herd on CGI. Instead, the Vermont Press Bureau’s Neal Goswami says, 

Optum found that accountability for program management is unclear. “Neither (the state) nor CGI believe they are accountable for project outcomes,” the report says.

Am I the only one who’s appalled by that? CGI was fired for poor performance; but state officials failed to make CGI “accountable for project outcomes.” As any business-school professor could tell you, that’s fucked up. And if CGI deserved to be fired, so do the government officials who played a big part in its failure.

And none of those officials are named “Doug Racine.” 

Optum recommended that the state hire a project manager with experience in handling large-scale IT projects. State health care reform chief Lawrence Miller says the state is about to hire such a person. 

Well, huzzah. That’s a little bit late, isn’t it? 

In March, TIME Magazine published a cover story about how the federal health care exchange was on the brink of complete failure last fall. The Obama Administration realized, belatedly, that while they had a lot of policy expertise, they were woefully short in IT. So they basically called the Geek Squad: a team of IT experts from Silicon Valley “dropped what they were doing… and came together in mid-October to save the website. … Washington contractors had spent over $300 million building a site that didn’t work, this ad hoc team rescued it and, arguably, Obama’s chance at a health-reform legacy.”

You’d think, after all of that, the Shumlin Administration would have known it had a huge challenge on its hands, and that it required both IT expertise and intensive management oversight to fix the health care exchange. 

Instead, only now are we hiring an IT expert. 

On Friday, in the Governor’s absence, Lawrence Miller and Health Access Commissioner Mark Larson released the Optum report. And their statements were not at all encouraging; they downplayed the significance of the report and the need for further action. Miller called the report “something of a snapshot,” although as Goswami says, “the findings… are similar to previous assessments by independent parties.” In other words, this report may have been a snapshot, but the picture has stayed pretty much the same over time. 

Miller also said the Administration would use the report “to make decisions about the best way forward with the project.” Well, that’s half right. But you should also use the report to assess the failings of the past — so that you stop repeating them. 

For his part, Larson was even more determinedly lipsticking the Optum pig: 

“On a broad level what we have taken, generally, from this report is that we have worked hard with our vendor partners to create a foundation for Vermont Health Connect.” 

I’m sure they’ve all worked hard. But I’m not convinced that they have worked well or effectively. In fact, if the Optun report is accurate, a lot of the hard work has been wasted or misdirected thanks to a lack of accountability and oversight. Working hard is not an excuse for failing to deliver the goods. 

Oh, and the other news from the ultimate Friday afternoon newsdump: on Optum’s advice, Vermont Health Connect has stopped working on fixing the system. Instead, it will try to make the incomplete system more customer-friendly in advance of the November-February open enrollment period. Further work on fixing the system won’t resume until after open enrollment. 

Great. Even as Governor Shumlin is unveiling his single-payer health care system and asking the Legislature to approve it, Vermont Health Connect will still be an unproven work in progress. 

You know, if I were a lawmaker, I’d refuse to take any action on single-payer until Vermont Health Connect is fully functional. The Governor can’t, in fairness, ask lawmakers to vote for a huge new system as long as the health care exchange isn’t working. 

I’m fully aware that single-payer will actually be simpler than Vermont Health Connect. On a policy level it makes perfect sense. But on a political level, you can’t take the next step in the process until you’ve successfully finished the previous one. 

Beyond the immediate situation, bad as it is, I have a more existential concern. Governor Shumlin earned a reputation as a capable manager in his first term, thanks largely to his response to Tropical Storm Irene. The endlessly-troubled health care rollout threatens his reputation for good management. And that’s why I’d advise him to step up strongly and take his medicine. And, yes, fire  the people who failed to hold CGI accountable. 

If he doesn’t, I fear the best days of the Shumlin Administration may be over. When you’ve been in office for a while, and the opposing party is in disarray, there’s a natural tendency to relax a bit, start seeing yourself as invulnerable, and pay more attention to your image than to the quality of your work. That is the beginning of the end for great leaders everywhere throughout history. Is it the beginning of the end for Peter Shumlin? 

And for single-payer health care?

If you can’t improve your product, get a better salesman

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Let’s start with the thesis (for once): I still don’t understand why Doug Racine was fired. I have some guesses, but the official story doesn’t wash. 

From Governor Shumlin, we’ve heard the usual “time for a change” bullcrap. From Racine, we’ve heard that the Administration wanted more of an “ambassador,” while he’d been keeping his nose to the grindstone at the Agency of Human Services. Racine offered the following comments in a Wednesday interview on VPR’s Vermont Edition: 

They mostly focused on style. [They said it wasn’t about the troubles at the Department of Children and Familes, and never mentioned Vermont Health Connect.] I had been focused on the Agency… What they said they wanted was somebody who was going to be out there a little bit more, in front of the media, and in front of local groups and constituent groups, and just to be talking more publicly about the good work of the agency. They said I wasn’t the right person to do that.

Well gee, Doug Racine spent a lot of years in politics. I’d think he could be an effective “ambassador” if needed. And if he believed in the product. Besides, a problem with “style” doesn’t seem urgent enough to warrant the sudden and immediate dismissal of an original cabinet member. Hell, Racine cleared out his desk right after his firing: they wanted him gone, and gone NOW. They didn’t want him wiping his hard drive or stealing office supplies. 

I don’t have any inside information, but here’s what I think. The Shumlin Administration knew it would be cutting the budget, and that most of the cuts would happen at AHS. They knew the agency was already overstretched, and that Racine had long believed it was badly under-resourced. 

I look at the ratios, I look at the work they do, I talk with a lot of the workers. They’re very stressed. They’re dealing with families in exceedingly difficult situations.They need more people, there’s no question about it.

And then Racine said something I found telling: 

 I met with some of the [DCF staffers] who testified [at Tuesday’s legislative hearing], I met with them last week, and I urged them to go and tell their story to the Legislature. …I’m glad that they were there, I’m glad they testified, and I hope the Legislature was listening.

That hearing gave voice to the frustration and despair among DCF staffers. In the context of this week’s budget cuts — which Racine had to know about last week — their testimony was a big fat warning shot across the Administration’s bow. And he encouraged them to speak out. Not very ambassadorial, that. 

When Doug Racine ran for Governor in 2010, concern about Human Services was one of his top priorities. As AHS Secretary under Shumlin, he has tried to stretch the available resources as far as he could. He was a loyal soldier, trying to preserve human services programs in very tough times and not complaining in public. 

And then came another round of cuts, and the primary targets, per VTDigger, were (1) the already overextended DCF, and (2) Shumlin’s pet project for 2014: substance abuse treatment. 

Do you think that might have forced a confrontation with Racine? It looks to me like the Administration not only wanted him to swallow more bad news, but wanted him to get out in public and actively promote the budget. He could have done the former, but he couldn’t bring himself to do the latter. 

Again, no inside information, just educated inference. 

The only explanation I can think of for the timing is (1) the pending budget cuts, and (2) the election campaign. Shumlin wanted a cheerleader, and Racine wouldn’t pick up the pom-poms. 

Meanwhile, the interim AHS chief, Dr. Harry Chen, is by all accounts a good guy and an able administrator. But when I read Terri Hallenbeck’s story in the Freeploid, I saw some obvious holes in Chen’s game. First of all, he describes himself as very much a hands-on manager coming to a job where that might not be possible: 

Chen… said the management style he brings to the job includes lots of interaction with staff. 

“I wander the halls,” Chen said, acknowledging that as secretary of an agency that oversees such a vast array of services, there may be too many halls to wander in too many far-flung buildings.

And Senator Kevin Mullin pointed out that “two key areas where Chen may lack expertise the agency sorely needs is in information technology and child protection issues.” Which happen to be the two biggest challenges facing AHS. 

Dr. Chen’s interim appointment expires at the end of the year. He’s got four months to “wander the halls” and, he says, make recommendations about changes in the agency. In his first day on the job, reports Hallenbeck, he met with central office staff to give them reassurance. But he’ll have to make some tough decisions in a hurry. Sort of like his former job as an emergency room doctor: get as much information as you can as quickly as you can, and then do what you have to do. 

Might be more blood on the floor in the not too distant future. And I suspect that when Dr. Chen isn’t wandering the halls, he’ll be facing the cameras and telling the people of Vermont something that sounds a lot like this: “These are challenging times but the Agency is up to the task, and the Shumlin Administration is giving us all the resources we need.”

Rah, rah, sis boom bah. 

So it was a push, not a jump

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Media reports posted after my initial VPO piece on Doug Racine’s departure make it clear that Racine was fired as Human Services Secretary; he did not resign. And he was fired in a sudden and coldblooded way. The best reporting comes from Paul “The Huntsman” Heintz, who got the skinny from the firee himself.

In a phone interview, he said he was summoned to the 5th floor of the Pavilion State Office building at 4 p.m. Monday for a meeting with Shumlin chief of staff Liz Miller and Secretary of Administration Jeb Spaulding.

“I went in and sat down. They said, ‘The governor wants to make a change at your agency.’ I said, ‘Who would that be?’ Jeb looked at me and said, ‘You,’” Racine recalled. “We talked about it for a few minutes and then I went to the office and cleaned out my desk.”

So now we know who wields the hatchet in the corner office. Shumlin did give Racine a call about an hour after the meeting, and it was relatively cordial; but hell, couldn’t he do the actual deed himself? Especially since Racine had handled the hardest and most thankless job in state government for three and a half years?

There was also a Profiles In Courage moment Tuesday afternoon, when Shumlin went kinda wishy-washy on the nature of Racine’s departure, i.e. voluntary or not:

Asked what, specifically, prompted Racine’s exit, Shumlin said, “Specifically answering your question is exactly what I’m not going to do.”

Well, at least it was a head-on refusal to answer instead of the usual “bury ’em in bullshit” routine.

When I call AHS Secretary the “hardest and most thankless job,” here’s what I mean. It handles a whole lot of disparate programs aimed at helping our most unfortunate. It’s a huge agency by Vermont standards. As I noted earlier, it was hit hard by the Douglas Administration’s ill-fated Challenges for Change initiative, not to mention its misadventures with technology contracts (which were at least as bad as Shumlin’s). And it was ground zero for the health care reform effort and all the attendant troubles.

In addition, AHS’ challenges were compounded by Tropical Storm Irene, which left a whole lot of people in need of help — and which scattered the agency’s personnel to rented spaces in multiple communities because of the flooding in Waterbury. And they are still scattered today. Not to mention the flooding and forced closure of the Vermont State Hospital and the ensuing years of chaos in the mental health care system. 

Doug Racine handled all of that with grace and dignity. He kept his nose to the grindstone and almost never uttered a discouraging word in public. I’d think that was a good thing, but apparently he was too quiet for Shumlin’s taste:

According to Racine, the governor wanted a secretary more willing to engage with the news media and interest groups.

“If anything, it was perhaps not being out there enough,” Racine said.

I always thought Racine’s quiet style was perhaps exactly what Shumlin wanted from his longtime political rival. Either that, or Racine himself opted for the low-profile approach because he didn’t want to come across as bitter or as a potential political threat.

As I said in my previous post, I understand the need for a sacrificial lamb. And between the problems with health care and DCYF, I can see why Racine got the axe. But the way it was done? I think Racine deserved better.

A head has rolled

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Shocking, but not surprising news this morning out of the capitol city. Paul “The Huntsman” Heintz:

Gov. Peter Shumlin has dismissed onetime political rival Doug Racine as secretary of the embattled Agency of Human Services.

“These decisions are difficult, but the governor felt a change in leadership at AHS was needed at this time,” Shumlin spokeswoman Sue Allen said Tuesday morning.

Doug 'n Pete in a happier moment. (Photo from VPR)

Doug ‘n Pete in a happier moment. (Photo from VPR)

Laura Krantz at VTDigger writes it as a Racine departure, not a firing. Which makes me wonder if the last straw was last week’s emergency budget adjustment, with its calls for further cuts in an already-overstretched agency. Maybe Racine stood up for his people, and got shot down for his trouble. I have no inside information on that point, but the timing certainly fits.

Whether a push or a jump, the shock is the suddenness of it all and the fact that the scythe took its first cut at the top level rather than, say, taking a Mark Larson or a Robin Lunge. It’s not surprising because sooner or later someone in state government had to take the fall for Vermont Health Connect’s continued troubles.

I say so not because any one of the three is more or less culpable for the VHC mess, but because Larson and Lunge were more directly involved. And because a cabinet member is a key gubernatorial appointment, this is a more direct reflection on the Governor himself.

But as Heintz points out, the trouble isn’t all health care-related. AHS’ Department of Children and Families has also come in for criticism following the deaths of two young children under its supervision. In that context, Racine was the most relevant target.

Health Commissioner Dr. Harry Chen will be interim AHS chief, with an appointment through the end of the year.

My take, and I have absolutely no knowledge of how AHS works or doesn’t: It was an almost impossible job. In fact, when Shumlin appointed his chief political rival to the post, I wondered whether it was an honor or an exile. AHS is a big, complicated operation that’s usually overtaxed and underresourced. Racine took the job after years of Jim Douglas-mandated cuts, and the disastrous implementation of Challenges for Change. It was the kind of job that was almost certain to leave Racine with a tainted reputation as a manager, especially with the Governor’s aversion to tax hikes and obsession with cost-cutting. And on top of all that, AHS was home base for health care reform and its myriad pitfalls.

It was a thankless job, and Racine kept at it for almost four years. And did his job largely out of the public spotlight, with a dignity and dedication that speaks well of him.

 

The Milne Transcripts, part 4: The Great and Terrible Doug Racine

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Yet another instlalment in my epic series of posts from Scott Milne’s horrific appearance on WDEV’s Mark Johnson Show on July 25. It was his first long-form interview since formally opening his bid for the Republican gubernatorial nomination, and it was bad on so many levels… 

One of the many intricate dances Milne was trying to perform was projecting an image of moderation without alienating the GOP base. A difficult task, given that some prominent GOPers are already talking up Dan Feliciano, the Libertarian candidate.

During an attack on the Shumlin Administration’s alleged managerial failings, Milne went off on a tangent about the 2010 campaign. As you may recall, after Jim Douglas bowed out of the race, five Democrats jumped in — and Peter Shumlin eked out a win in the primary, with Doug Racine finishing a close second. Take it away, Mr. Bunny…

I would have loved to have seen a Brian Dubie/Doug Racine governor’s race. I think Doug Racine is an accomplished state public servant, a man of great integrity, and I would have loved that governor’s race. I would have supported Dubie in that, but I thought that would have been a good governor’s race with two very different, um, paths forward for Vermont. But where I would have felt like both people were just being totally candid about what they thought, and not trying to read polls and figure out what they needed to say to get elected.

Got that? Liberal Democrat Doug Racine, man of integrity, “accomplished public servant,” and quality gubernatorial candidate, unlike the unprincipled opportunist who won the nomination, and who shall remain nameless because Milne has declared that his campaign will not “vilify” anyone. (Just as I am not vilifying Scott Milne, a fine businessman who possesses many fine qualities — political skill being conspicuously absent from the list.)

But this remark was preceded by a direct attack on poor management at two agencies: Natural Resources, and Health and Human Services. The latter helmed, of course, by none other than Doug Racine. Just before this, Milne had slammed Governor Shumlin’s so-called “Team of Rivals” cabinet that included some of his adversaries in the 2010 primary. Milne said “I don’t think those were good management choices.”

Okay, so I guess the “accomplished public servant” Doug Racine would be a crackerjack candidate for Governor, but he has no business heading a state agency?

Of course, Milne made it clear that he, personally, wouldn’t have voted for Racine, but still: making Racine the Democratic nominee is putting him in line to run the entire state government, when you think he’s not even capable of running a subset thereof. It’s like saying Sarah Palin was a darn fine candidate but would’ve made a lousy Vice President.

It was a very poor way to make a very weak point. Milne apparently wanted to have something good to say about a prominent Democrat in order to burnish his bipartisan credentials. In the process, though, he managed to compliment and crucify the same person in the space of two paragraphs.

Stay tuned for more installments of The Milne Transcripts, coming soon to this space. But first, I gotta do some weed-whacking. 

The new state hospital: A milestone, but not the end of the road

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Yesterday’s happy-smiley ribbon cutting at the new State Hospital in Berlin was, indeed, a happy occasion. The post-Irene period — almost three years — has been extremely tough on seriously ill patients, their caregivers, and the entire mental health care system. Long waits, days spent in emergency rooms, endless shuffling of patients from one facility to another, constant searching for even a single empty bed. It’s been damn tough, and the interregnum has been longer than it should have been.

But nobody should confuse this milestone with the finish line. There are still a lot of questions to answer and issues to address. (Many of these were covered in Pete “Mr. Microphone” Hirschfeld’s fine piece for VPR, which went above and beyond the pro forma coverage of a ceremonial event and actually addressed the meat of the issue.) First and foremost: is this new hospital big enough?

After Irene, the experts were insisting that a new hospital needed to be at least as large as the old one. Instead, it’s half as big. I realize we’re trying to deemphasize hospitalization and move to a multifaceted, community-based system. But we’re talking about the sickest of the sick: even at 54 beds, that’s one bed per 11,593 residents. A central hospital isn’t for patients who might be better served in outpatient or community settings; it’s for the very, very small number of people who are too ill to function, too dangerous to themselves or others.

It remains to be seen whether 25 beds are really enough. It’ll definitely ease some of the intense pressure on the system, and it should prevent the widespread warehousing of patients in ERs or other unsuitable locations.

And there’s still widespread legislative dissatisfaction with the cost of the new facility, which makes me fear that the hospital will be nickel-and-dimed by lawmakers more concerned with the bottom line than with adequate patient care. Sen. Jane Kitchel, for one: she was more than pleased to take part in the ribbon-cutting, but she’d really like to see the hospital run more cheaply. 

Many lawmakers are complaining that the new hospital’s per-patient costs are substantially higher than the old one’s. That’s true, but I’d point out a couple of obvious items:

— The old hospital was inadequate. Everyone says so. It lost its federal certification, which meant it did not qualify for Medicaid funding. If the old hospital wasn’t up to snuff, well, of course the new hospital will cost more.

— Many of the costs are fixed. So when the Legislature happily signed off on a smaller facility, it tacitly agreed to much higher per-patient costs. A brand-new 54-bed state hospital would have had higher operating costs than the old one, but it would have cost a lot less per patient than the new 25-bed facility. This shouldn’t be a surprise to anyone in the legislature.

— Many of the costs of the old state hospital are now redistributed across multiple locations, and helping to fund new community-based programs. (Or at least that’s the way it’s supposed to work.) This very intensive kind of psychiatric care requires staffers with special training and expertise; in a single central facility, you can have a more concentrated level of expertise. In the new system, we’ll have to spread those people around. And almost certainly hire more of them.

So I don’t want to hear any whingeing from the legislature about the new hospital’s cost. This was their idea.

But it must raise serious questions about the legislature’s willingness to fund the community-based facilities that are supposed to undergird the whole system and prevent a whole lot of hospitalizations. <a href=”http://digital.vpr.net/post/after-long-wait-mental-health-hospital-ready-first-patients”>Via Hirschfeld: </a>

Northfield Rep. Ann Donahue is a mental health advocate who has spent years advocating for a new state mental hospital. Impressive as the new facility is, Donahue says the system won’t function properly unless the community-based facilities are actually built. And she said much of the bed space and treatment capacity called for in the reform plan have yet to be constructed.

“Some of them are still in development, some of them are on budget hold. And we need to really enhance that aspect or we won’t reduce the need for inpatient care,” Donahue said.

At the ribbon-cutting, Human Services Secretary Doug Racine trumpeted the claim that Vermont “has the best mental health services in the U.S.” As of today, that claim is one step closer to reality but, fundamentally, it remains in the realm of political blather. The truth is, Vermont may well have the best mental health care system in the country ON PAPER. But a long struggle remains to turn it into reality. And penny-pinching Democrats are, sad to say, the biggest obstacle in our path.