State therapists brace for new structural changes

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Therapists for a state service that helps infants and toddlers with special needs are worried that changes in the way the program operates could hurt the quality of care for the children in it.

The Indiana Family and Social Services Administration is in the early stages of rolling out several reforms to its First Steps program, which provides in-home speech, occupational, physical and developmental therapy to children up to age 3.

One of the key changes is requiring that all service providers be part of an agency that employs at least 12 therapists and operates out of a public location open during business hours five days per week. That would mean the roughly 1,000 therapists or very small businesses who now contract directly with the state would have to find jobs with those agencies.

And that’s raised myriad concerns. Among them is that some of the talented therapists will leave or be forced out of the field. Others worry that the agency structure will limit the time they can spend with their clients—and limit parents’ flexibility in choosing who works with their children.

“They’re adding a middle man,” said Rion Lahr, an Indianapolis speech therapist who works for the First Steps program. “With an agency it’s always the bottom line. With independent [therapists] and small companies, it’s what’s best for the child.”

But state officials, who decided on the changes last month, say a shift to an agency structure will enhance the service by improving communication between the various therapists serving a child.

They also say it will help fill a gap in the number of therapists serving children in rural and inner-city areas. Such a disparity has been created because therapists have been able to choose their own service territory. The agency also projects the changes would save $2 million a year—an important factor because the program faces a sizable deficit.

“We wanted to make sure we were living as much as we could within our means,” said Dawn Downer, First Steps’ director. “But we also wanted to make sure we had a program that provided quality services to the families we serve.”

This year, the First Steps program, which is funded by a combination of federal and state dollars, insurance and small payments from families, is aiming to cut $9 million of its $71 million budget to help head off a $15 million shortfall.

Part of the savings would come from cutting therapists’ pay rate by 5 percent.

Downer said the move to an agency model also would save money by helping the program better target its services.

Currently, parents with children in First Steps choose their therapists from a list on the program’s Web site. Some children require several types of therapy, while others may only require one.

Under the changes, families would be able to pick their initial therapist, but if their child required another type of service, the other therapist would have to work for the same agency as the first.

Having therapists from the same agency work with a child, Downer said, would allow the therapists to collaborate more. They then could better identify their clients’ needs and cut down on redundant or unnecessary treatment.

But some parents in the program say it would hamper their options.

When Becky Hufty’s now 3-year-old son, Jack, participated in First Steps, he was switched from his original occupational therapist to another who had more expertise in the type of service he needed. Jack has problems with his esophagus, brain and spine that accompanied a premature birth.

Hufty, of McCordsville, worries that parents in the program won’t have that same flexibility under the new system.

“You have so much trust in what the therapists are doing with your child,” Hufty said. “You need to have the option to choose who you’re going to work with.”

Lahr said she’s concerned that the agencies will not have enough room to absorb the 1,000 individual or small-business therapists—about 70 percent of the therapists in First Steps. Even if they do, she thinks top-notch therapists will leave the program out of frustration with the new system.

And she worries that the agency structure would limit the time she spends with her clients. Now, for instance, she’ll spend an additional 15 minutes to as much as an hour with the children if needed, but with a more structured agency system, she says she wouldn’t have that luxury.

“The children get would less service,” Lahr said.

Downer understands that therapists are concerned about the change, but she says their concerns should not take precedence over what she sees as best for children in the program.

“I hope most of these providers can also look at the greater good,” she said. “This program is very valuable to the children and families that they serve.”

Therapists’ transition to the agencies is expected to begin next month. The changes will go into effect next year.


  • Agencies what agencies?
    Supposedly therapists are to be enrolled in an agency by 1-1-11 or they will no longer get authorizations for new children. BUT not one agency has been approved yet! There is so much gray area in what First Steps is requiring, and what the agencies are able/willing to provide, that several that were very interested are now throwing up their hands and walking away. So now how do you even sign up in small rural areas, which is what I currently serve. If today is 12-13-10, and not one agency is approved, then how in the world is the state going to process all of their applications, and transition all the therapist to them by 1-1-11. There is no possible way.
    And "frustrated provider" there is no way anyone is seeing 35 kids a week, unless they all live in the same apartment complex. There is a minimum of 10 mins we are required to document between visits and by the time you write your face to face sheet, load your equipment, drive, get your equipment out, change out what is needed for a different child, and go in the house, wait for them to finish feeding/diapering the child you are going to see, and actually start your session, it's at least 20 to 30 minutes, even if the child is 1/4 of a mile from the previous child. In the "underserved rural areas" it's often 30 mins, actual drive time. In 3.5 years I have had 3 times that I've actually seen every child on my caseload. I have had weeks where w/gas prices going up, and the times I have arrived at the exact appointment time, only to be told that they can't do therapy that day, or won't even answer the door, that I have actually lost money.
    And whether we are agency or independent, we do not get life, health, dental, short/long term disability, retirement, vacation, paid time off for any reason, mileage, drive time, reports, phone calls, emails, trainings, etc. We get paid for the 60 minutes we are on the floor with the children.
    So here's to another therapist that is currently job hunting. I may make a lot less on the hour, but in just money, I'll come out ahead. . .in satisfaction I will probably be miserable. My husband often tells me this is the only job, I can leave the house in a bad mood and come home in a great mood after seeing the progress my children have made. But since the state's bottom line is money, I will have to make that my bottom line too. And I don't make enough to put up with this much confusion, drama, and grief. BUT THANK GOD WE FOUND A WAY TO MAKE EVERYONE IN 5 COUNTIES PAY FOR THE COLT'S NEW PLAYGROUND! That is so much better for the state than getting children the start they need and deserve to help lower the amount in special ed in the public schools.
  • It's too bad...
    It's too bad that this strong program of First Steps, strong because of the great professionals who work in it, has to be torn apart. We are trained professionals who care about our clients and work hard at unity in the team work. But now, the state is tearing the program apart by making it competitive. Agencies are scrambling to find providers to sign on soon enough that they can prove they can be an agency. Providers are trying to figure out which agency to sign on with--even though we don't know which agencies are going to be approved. This process is dividing.

    The providers recognize that budget cuts have to be made. And we proposed ways to cut the budget in ways that made sense. So, this could be a wonderful time to build unity. To make First Steps an even better program.

    It's like the show Survivor--what could be a wonderful team-building experience that brings out the best in everyone, has turned into a scramble and fight for survival. It's not making the system stronger.
  • Please explain, Dawn!
    From the beginning of this discussion, I have tried to understand where the state was coming from. I understood that the economy was greatly affecting the budget. I understood there were organizational issues impacting First Steps that sometimes affected quality of care. But I still fail to understand how this addition of bureaucracy will solve any of these problems.

    PLEASE EXPLAIN how having therapists work under an agency will save money. At present, there is no plan to have the agencies bill for services. If that were the case, I could at least foresee how the state could improve their bottom line. Rather than simply having a training for the providers (we all have FSCT requirements -- just make this one), teaching the importance of correct codes and paperwork, First Steps has decided to overall the entire system. I expected more from Mitch. I understand he has delegated this issue to Dawn but, obviously, he chose incorrectly in his leadership. This change will only save the state money from the 5% reduction and, perhaps, a little more money from correct billing (again, just train us, rather than the agencies).

    PLEASE EXPLAIN how having us in agencies will improve communication. Most providers are going to maintain their status of contract therapist. This means we will rarely come to the office, as we will spending most of our time seeing kids. I currently communicate consistently with most of my teammates. As issues arise, we talk. I care about the children on my caseload and strongly believe team communication is important. That will not change, because I'm part of an agency. Bad therapists will remain bad therapists, as independent or agency providers.

    PLEASE EXPLAIN how reducing providers' incomes by 15-20% will help to expand the areas we serve. I know of several providers who are strongly considering leaving the program, because of the pay cut and the frustration with First Steps.

    As a fiscal conservative, who strongly believes in balanced budgets, I was ready for a pay cut (heck, I hadn't had a change in pay since arriving in IN 5 years ago -- can all our state workers say the same thing? I think our congress just got their annual increase...). But to be forced into an agency, have my pay significantly cut and have little to show for it in the state budget, it's just too much. I'M VERY DISAPPOINTED, MITCH! I thought you were my man.
  • Yea, right
    Let's get a little honesty here: as with anything under the oversight of Jim Payne, this is exclusively about money with no consideration of the best interests of the children or families. That's how he ran his court, it's how he runs DCS and its now how he wants to ruin a very beneficial program. All the flimsy, unsupported claims of better service were made up for a prettier justification for what they are doing.
  • Open your eyes
    I don't know who you have been working with but some of the finest help I've had for my child were Developmental therapist. I appreciate the "whole child" and "big picture" aspect of their intervention. There are probably some who shouldn't have this job but the same can be said for other individual therpist who are P.T. Ot, etc. I'm sorry you haven't been able to work with some of these fine therapists. What a narrow and exclusive view!
  • Who are you?
    I don't know what kind of a therapist you are, but you are sadly mistaken about DT's. I am an O.T. and I have worked with the most talented and professional D.T's. The D.T.s I have had the privilege to work with are well educated and have made sure they know about areas that other therapists generally address so that they can help with language development, sensory issues and positioning to name a few, as well as building education into play for the young child. I have a lot of respect for the D.T.s I work with and I value their input and insight. I know the families that work with D.T.s value them as well. If they didn't, they could certainly choose not to have them come into their home and work with their child. I think that it is very short sighted to take a whole group of professionals and claim that their work is not valuable- Shame on you!
  • Want to cut the fat? The truth hurts.
    I am a therapist and a mom with a special needs child. One thing I can tell you, when the kids get into the school system they will be with a teacher most of the time and the therapy goals are incorporated. They will get pulled out for therapy, or therapist will work with them in the classroom-sometimes.

    The majority of developmental therapists are not really 'qualified', and have not met the same standards or licensure qualifications with IBESPA or have a teaching license like other disciplines. Keeping that in mind, my colleagues tell me that they pick up kids who are 2 y.o. and have NEVER been seen by an actual qualified 'therapist' as of yet, only a DT, who is often unqualified. So much time has been wasted on a DT coming in and not really addressing the meaty issues that need to be addressed with these kids because the unqualifed DT has been in there doing NOTHING, and of course - who loses??? THE CHILD!!! Remember- it's not about you and your ego and your bottom line- it's about THE CHILD! What is best for THE CHILD???? Remove DT's completely, and have therapists, RD's, and Psychologists working with the child from day one and 'front load' the care with therapy for 3 years. Then, when the child goes into the school system- they have already had many of those foundational issues addresse,and the teacher and therapists can support them through the educational model more efficiently. Politics and egos need to be set aside. Yes, business is business and I understand we all have to think about our bottom line. So, if that is the case, then get rid of the DT's. Sorry, don't mean to offend. It is what it is. The state needs to be told like it is for a change and no dancing around the issues because we 'don't want to offend' the administrators or being afraid of our jobs being in jeopardy. Well, guess what?? Jobs are in jeopardy - and the CHILDREN ARE LOSING OUT! BIG TIME! Get a clue, people. Oh, and by the way, I am a therapist of 20 plus years, and working for an agency will do nothing but add to the bureacratic structure which currently frustrates us! Most independent providers are part of an informal network, so that issue takes care of itself. Most therapists of 20 plus years who are independent providers do NOT want to work for the big agencies. There is no point. Sorry. Quality is generally better when provided by Independent practitioners. I will pray for all of those kiddos who suffer from this!!
    • Kids will lose
      Dawn Downer was quoted in this article as saying, â??This program is very valuable to the children and families that they serve.â?? We, the providers, know that. That is why we are fighting so hard. We see the huge problems these changes are going to make in this program. Changes that will make services more limiting to the families/children. Changes that negatively affect the families. Yes, we don't want to give up our small business/independent status--there is no reason to do so as it won't save the state any money. But, we are also VERY concerned about the families--their freedom to have the best therapist for their child is taken away. The families have received outstanding service through First Steps because of the providers--who are professionals. We will still give our best. But, dummying down the system will hurt the families.
    • Very scary
      As a citizen, it is VERY concerning to me that government officials are able to make HUGE changes to programs without any accountability. Who approved these changes? Who is being held responsible? I'm stunned at the lack of organization and communication between the state and families/providers. Have families been made aware that they may lose their providers? I don't see many good therapists sticking around to see how this mess shakes out. I guess we'll see how our infants and toddlers do without the services they need and deserve.
    • blah blah blah
      How does putting providers into an agency increase their communication with other providers? Providers will still be working out of their homes. We won't be going to the agency daily, even weekly. We will continue to do our job as professionals and be in contact with the other providers on the child's team just as we do know. But, that is not enhanced in an agency setting. We are out and about all day seeing clients. We don't have time to sit around a clinic and chat. We make phone calls and send emails between clients and in the evenings. I don't plan on spending my evenings at any agency. The inter-provider communication is because we are professionals. Not because the state adds a middle man.
    • asinine
      The change to put providers into agencies is idiotic. But, the proposal to have service areas is just plain asinine. It is not the answer to getting therapists to work in under served areas. It is very limiting to where a provider can now serve. I serve a larger area as an independent than I will be able to serve once I work with an agency.

      And, some of the under served areas are scary areas to work in. The areas of Indianapolis that have the highest drug and homicide rate is one of the areas. A provider was car-jacked at gun point in one of those areas.

      The state has the right, per federal guidelines, to make other plans for children in those areas. If agencies force therapists to work in those areas, then who is liable if the therapists is hurt or even worse killed?

      Providers have supplied some ideas for how to make these types of areas safer to work in. But, once again, the state did not listen to us.
    • Please explain...
      The state obviously doesn't know how to make the changes that it is trying to make. Providers are told differing information on the changes. We are told an effective date but are not given new policies and procedures on how to fulfill that change. We then ask for clarification and are told that certain changes have not been figured out yet so we don't have to follow them yet. They are making changes without knowing how they are going to implement and fulfill them. What kind of a business plan is that? The changes do not make sense, but at the very least they should be planned out before being announced and made effective.
    • Parent of a First Stepper
      I am really disgusted with the lack of input solicited from parents and providers prior to the proposed changes to the First Steps System. Little thought was put into the proposed changes to the First Steps program. If it's a matter of budget concerns there are many, many other ways to save money than on the back of Indiana's youngest citizens. Families having to choose only an agency will affect choice and promote a less competent therapy pool to choose from. My child's therapists have done an excellelnt job of communicating with each other and with our family without the extra beauracy of a large agency to deal with. These proposed changes will only impact the potential of babies and young children in a negative way. First Steps leadership appears to be more concerned about the survival of large agencies than of the little ones in need of therapy.
    • This is only the beginning
      There will be more cuts. The 5% is for Dec. 1, but i expect there will be an additional cut of 10% next year, in two increments, so the 15% cut is across the board. (The SPOE already took 15% this year). The new networks are in for a surprise expense when they will have to be credentialed by an accreditation organization like JACO,etc. By the way, the accreditation application and process cost was $50,000 in 1995, so i do not know what it is now. So whatever is being offered to providers now is only for now. It will be less when they have to factor that new expense it (additional cuts by the state and accreditation expense). Download the state accounting information that anyone can see, and you will see the state is planning for another cut. Providers beware when you sign up with a network, your new wage is only for now and for only a short period of time.
    • Load of crap
      Sad day for parents in the therapy world! My daughter was signed up for FS on day 2 of her life in the NICU. We made strong relationships with our therapists and they are family to us. We had choice on our therapists and chose wisely based on recommendations from other families and hospital staff. Although none of the therapists worked for the same agency, they had no problem collaborating and getting on the same page, AS THERE IS SOMETHING CALLED EMAIL AND PHONE COMMUNICATION. State people, email is fairly new, I understand, but trust that adults who need to communicate with each other about a child will figure out a way!

      I'm glad my FS days are over if this is the way that treatment is going to go. Kids really aren't are future anyway, right?
      --Pissed parent
    • DT
      Change is the only thing in life that is consistent, however, all changes are not good or in the best interest of others. I have worked on both sides. There was no more communication between therapist in the agency than I have now with other therapists for the children I serve. I can always contatct the other therapists to learn how things are going for that child. An agency will NOT change that. Pay cut? yes, please have ALL those in First Steps get the same pay cut including paying angency to be part of it. That should help reduce the budget even more. Placing providers under an agency will not help increase therapists in rural areas or inner city. Therapists will look for the agency that serves an area they are willing to travel too. I do First Steps work for the children and families as well as most independents. I am sure I am not the only therapist that travels to places that are not close to their home. I have been working in First Steps over 15 years and the children and families deserve these services. Now DT's that have been in the system and have taken trainings to continue their credentials may be placed out of the system. DID WE NOT LEARN ENOUGH FOR YOU?? DO WE NOT HAVE ENOUGH EXPERIENCE FOR YOU?? WHAT ARE YOU DOING TO THE FAMILIES?? Soon they will learn there will be a shortage of providers and the families and children will suffer even more.
    • Stopped at the starting gate
      With the addition of today's announcement regarding the takeover of ED Teams under soley the SPOE, there will not even be enough ED Teams to evaluate the number of children in need of services. The SPOE has a ridiculous plan to employ only 16 evaluators total to carry out all evals for Cluster G. I have been a member of an established agency and ED Team that on any given day, has a minimum of 8 therapists per day completing an average of 4 evaluations per 2 therapist team per day. Even with this number, there is typically a 2 week wait for families to even begin this first step of the First Steps process (followed by 2-3 weeks if they qualify before the ongoing services are even initiated-IF a therapist is even available). Now correct me if I am wrong, but HOW is this "new and improved" structure which will allow for children to be served in even a less timely manner, provide a better service to them and their families?
    • A Horrible Short-Sighted Decision
      The people who made this decision fail to understand that the cost of these changes to Indiana will FAR exceed the short-term budget cuts made now. The independent providers in First Steps are generally therapists with exceptional skill and a high level of dedication and concern for our children. The sad thing about these changes is that our children are going to lose the services of many of these providers. MANY are simply going to discontinue with the program. The pay cuts and the additional layers of hassle will simply not be worth it for many. The State should be honest about this. The decision has NOTHING to do with helping children. Clearly, children are going to suffer more. It is all about budget cuts. How short-sighted. Very simply...this is just tragic.
    • Helpless Parent
      Please tell me how cutting budgets for a program that helps our children is fair. Parents that are doing everything in their power to help their children and many have no where else to turn. We have lost one therapist that our daughter adored and responded to thankfully we found one that is equally great but what happens when they are forced to leave. How can we look our children in the eyes and tell them we honestly did everything we could but we just didnt have the money.
    • Just Tired
      Having worked both sides of the fence through the school system and first steps, it is very sad to watch the insane changes being made at the school level trickle down to first steps. As a previous poster stated, Indiana does not maintain caseload caps so I commonly was forced to fit 5-6 preschoolers around a table for 20 mins and try to be effective. Obviously I wasn't and thought I had found professional satisfaction with first steps as the last place where I could actually do my job well and make a difference. So much for that. It is possible to make a decent living at the current rate IF all your kids show up every week. They don't...and there is NO WAY you could see/bill what "frustrated provider" claims. I tried to get to 20, not enough kids even with me being the only open provider and would consistently lose 3-5 a week due to illness, appointments etc. I resent the jab at therapists that the shortfall is all our faults. First Steps does not give enough information to beginning providers about the paperwork side and then has a cow when they audit you because you didn't follow the 15 things they want on a face to face sheet when NOONE told you to put those things on there. I am intelligent and can follow directions. I only have to have access to the directions. I'm out of the system come the end of the year and I take my 20 plus years experience with me. I would hate to be a kindergarten teacher in 3 years and I hope the state has money to hire alot of 3rd grade teachers when the kids don't graduate to 4th grade because they can't read. This whole mess makes me tired and sad!
    • meeting with Mitch
      I have tried to arrange a meeting with the governor for approximately a month. No one from his office will call or e-mail me. I will continue trying.
    • Saddened
      As a parent of a former FS child I am saddened to know that such a wonderful program is being ruined by what seems to be mainly money issues. I dont think the people making these changes realize how it will affect current and future clients. Not to mention the WONDERFUL providers who will be forced out. Parents have enough to worry about, they shouldn't have to worry about when they'll lose their therapists, they shouldn't have to worry that they might never have the best therapist, and they shouldn't have to worry that their child wont get a therapy because there isn't a therapist available. Being with FS 2yrs I cant imagine going through those changes. You become very close with the therapists, so do the children. Its wonderful having a child doing things you were told she would never do. Its even greater to know that it was made possible with the help of the WONDERFUL therapists. Therapists that I was able to chose by ratings or recommendations by friends and former clients. Im sure that we can write until we are blue in the face but until the changes are put into place the real effects wont be seen. I hope the best for everyone involved. I hope the persons in charge of these changes think about the current and future children of FS.
    • Sorry
      That last post of mine was a reply to ACC/OTR....
    • How about Channel 6?
      We need Rafael Sanchez!!!
      • MITCH ET. AL MUST GO!!!
        Nothing about the way these changes are taking place surprises me. We live and work in a state that has little concern for public education after all. I guess those of us who will be paying student loans for 30 years because we put in countless hours toward master's degrees etc. shouldn't be surprised that public officials with less education, experience, and respect for the field of education don't prioritize programs like First Steps and public education. Mitch and Tony Bennett are doing all they can to make our educational system even worse than it already has been. It's actually laughable. Tony made this huge deal about honoring educators last spring. Did you know that some of those teachers he gave plaques to lost their jobs because of our state's cuts in education? What a pat on the back.... I understand that budget cuts have to occur in a "bad economy," but as one person stated, the end result will cost more with the cuts they are making. Nonetheless, these horrific changes are just filtering down. Anyone who truly understands education and bases decisions on research and evidence based practice knows that before age 7 children exists a critical language learning period. The earlier and better inverventions are, the better chance a child has to succeed. These changes with First Steps certainly complement the fact that Indiana continues to hold the highest average caseload for school SLPs, does not have public preschools funded by the state as other states do, and continues to have stats that put our children--our future--to shame. It all goes very nicely with No Child Left Behind. Just one bad policy after another. Four star schools lost their statuses as such because of their special education populations negatively affecting their test scores/performance due to NCLB. I honestly am surprised after all of these things, and now this with First Steps that there aren't mass riots being held by therapists, educators, and parents to protest. We will soon be able to add "the delayed get more delayed" to "the rich getting richer and the poor getting poorer." Pardon the random thoughts of this post--my anger toward all of the negative changes and the resulting impact it will have on my children just pushed me over the edge after the most recent updates I've received.
        Would it help to get the T.V news media or Indy Star involved here? People mention Mitch but how do we actually speak to him? Any suggestions?
        • Thoughts
          As a first steps provider, soon to be former provider, it saddens me to think that the kiddos in the areas that I serve are probably going to lose services that they are receiving right now because of this change. It is also is interesting to me that no one has considered the ramifications of the 0-3 population that won't get serviced and how that will lead to overpopulation of special needs students in K-12 because they were not helped early on. We are struggling to service our special needs populations now and with these changes more kids won't get services, parents won't get the education and time they need to continuously help their child and many good therapists are going to not only loose their job but take their expertise to other states or into other fields. Kids, parents, and providers are the only people who are getting hurt with this change. So how has this change helped or fixed the problems that the state was experiencing?
        • Evidence?
          I have requested and seen no EVIDENCE that the changes in process will do anything except enhance the profit for large agencies, and reduce employee satisfaction. The children and families First Steps is supposed to serve are NOT a consideration here. The agencies I have talked to to join have made no mention of how they will enhance communication. They also have no more idea than an independent about how they will provide services to underserved areas. You can't demand enhanced drive time to provide services to a child if no one is paying for gas, mileage, time spent traveling.

          "Frustrated provider" fails to mention that the rate listed is being cut by 5% by the state then another 15% taken by the agency to do almost nothing for the contracted staff. As before, therapists are still required to pay 25 - 33% of their pay as taxes.

          This change doesn't appear to help anyone. Please, someone show me the research/evidence that quality of services is likely to improve after changes!!!
        • Really
          Frustrated provider failed to mention that the hourly rates she is quoting are gross. We have to pay taxes on those, buy our equipment, our drive time is not included, or any other communication time. Really our pay is 30-40% of that. Yes I work part time for first steps and part time for a nursing home and I make the same both places after taxes. So may be you need to check your fact. Really there is going to be no program whether the state opt in or opts out when no providers are left to provide services.
        • So Sad
          I'm a previous FS provider. I couldn't stomach the system, lack of accountability, deceit by the state (Dawn, et. al) and practices shoved down our throats. None of this surprised me as I have sat in on some state level meetings. It sickened me then, and it is even worse now.So glad I left and took my experience with me!
        • Seriously??
          All the OT's and PT's who serve the county I work in, will be leaving the First Steps program! The state will certainly save money because the kiddos will not have providers! With all the cuts and regulations, I can no longer afford to stay! I have to provide for my family, too! This is so sad as I have been a First Steps provider for 13 years and I LOVE the families I have the opportunity to serve! But once again, the people in the "office" were unwilling to speak with those of us who carry out the services! So sorry children and families that you have been so poorly represented!
        • It's a shame
          Shame on Indiana...too bad you didn't do the right thing and bring all of us therapists in to suggest ways of cutting costs. Don't pretend it's about serving families better, it's about money for Indiana, nothing else. What's next...clinic based? It's cheaper for the program... those Medicaid rates are what therapists will be expecting next.
        • response to frustrated provider
          I am amazed that "frustrated provider" claims we cannot make more $$ anywhere else. He/she quotes the rates as if those are per hour, when in fact those rates (now reduced by 5% plus whatever the agencies want to skim off) include not only the hour with the child, but drive time, billing time, note writing time, communication time, planning time, equipment cleaning and replacement time ... not to mention that none of the annual training (20 hours) is paid time. Excuse me, "frustrated provider", but I can make more $$ in many different therapy settings. Why, I have a friend who make $65 per 45-minute visit in home health care, with less stuff to do at home every night. Or another who makes $45 per hour in a nursing home (which is about what I make (until Dec 1)as First Steps PT after everything is calculated).
          Now you can take about 20% off that $45/hour. So am I that well paid, "frustrated provider"???
        • corrupt government
          Another major point this article failed to mention was that Dawn Downer refused to meet with any providers or parents when making these so called cost saving cuts. She only sat down with agency owners to make decisions, and refused and did not respond to provider requests to meet with her. It seems extremely interesting that the ones sitting down with her are going to profit the most, while the children, families, and providers will be getting all of the cuts! How very sad and corrupt our government officials are becoming...
        • pay cut
          the article failed to mention that providers also receive a pay cut, to the tune of 5% in base pay for every service, plus the agencies skim another 10-15% off the top. That follows a 6% cut that occurred in 2002. Now did I read that the head of First Steps in Indiana says that she values the program and those providers? Funny way of showing it.
        • Agreed
          Being a therapist, I am very upset with this whole situation, mostly because we dont have a clue what is going on. We receive email after email with more information, but no one answering any questions or explaining how any of this will work. I've been very upset to see the forced changes, and the reflection on my pocketbook scares me. Not only are we hurting our kiddos, we are hurting the ones who are helping the kids. Come on, Indiana. Let's do the right thing! Early intervention and education is the best thing for our children, and we need to start putting money back into it!
        • "Frustrated provider" is Dawn Downer
          "Frustrated provider" is not a provider.
          Nice try. Your strong opinion is a little too scripted to be a provider. "We need a system that is sustainable for today and tomorrow." Let's see,...hmmm...that sounds familiar,...who said that??? Shameful. Where are your ethics?

          Here's a question,...In a coulple of months, just let us know if it was worth imploding an early intervention system?

          The people are speaking. Listen!

          Providers(professionals) have worked hard to make the system work to serve the people. There better ways to save a buck. You are out of touch and you are no provider. Learn to serve, then you can lead.
        • What!?
          I don't think the so-called "frustrated provider" is anything but a wolf is sheep's clothing. I have been trying to hold my tongue since I am no longer a First Steps provider, but I can't sit back and see this happen to a program that I put my blood, sweat and tears into for three years without voicing my opinion. NO professional in their right mind goes into this line of work for the money. Certainly we all hope to make a fair wage, but the numbers stack too high against our favor because there just aren't enough hours in the day. Personally, I was never off the clock. Since we work from home as independent providers, I was constantly doing job-related work when I was home in the early mornings, evenings and weekends. It never stopped. That is part of what drove me to accept another job 4 months ago (just in time, apparently!). I would carry a caseload of 20-24 children in hopes of a full week every week, but only averaged around 17 or 18, no matter how hard I worked to reschedule the missed sessions. I now work a straight 40 hr week, leave my work at work when I go and I make MUCH more income than did as a First Steps provider, not only in wages, quality home time, but the benefits I receive as an employee that cost me hundreds of dollars as a self-employed provider. The agency that I was originally employeed with when I began with the First Steps program actually took 1/3 of my hard-earned money to "bill" for my services and had little to no support for me as an employee otherwise. Billing literally took me 5 minutes a day when I finally figured out that I was better off self-employed. AND I had a wonderful support system of other providers that helped me through the transition from agency to independent. SO...just goes to show that I had better communication with other providers as an independent than as an agency employee. I learned so much from these other independent providers. I wish more parents knew what was about to hit them with these changes, but that has been convienently kept from them. I am so sad for these kiddos that will have inferior services and for my therapist friends that will lose all that they have worked for many years build. And for myself, as I hoped to be able to go back to First Steps, which is where my heart is, when I was more finacially stable and able to roll with the variabilities in income that come with this line of work. These changes will do nothing but further hinder an already broken system.
        • Concerned Parent
          I see a lot of comments from providers so I felt the need to comment as a parent. I had a child in First Steps for one year. At the time she was enrolled in FS, there was only ONE therapist available in the area where we live. I had no choice for a provider at that time, so it's apparent that the shortage of providers has been an ongoing problem. At one point during my child's enrollment in FS, the therapist went independent. She called to explain the change and frankly we saw no change other than the name at the top of our forms. She provided the same consistent therapy she did when she worked for an agency. In fact, she spent extra time with us to help us find resources we could use at home, talk us through some options for continuing therapy after FS, and providing some websites and reading material. All this was done outside of the "billable hours" everyone talks about. This therapist truly had my child's best interest at heart. The state is the reason things aren't billed properly. When I received my invoices, they were months after the services took place. It was not until a year and a half AFTER my child was enrolled (6 months after she aged out of FS) that the state took the step to attempt to get reimbursement through my private insurance.

          Two years later, I now have a second child in FS. Some changes were noticable right away. The most significant one being that it took me a month and a half to even get in touch with someone from FS. I was hours away from contacting the Governor's office to try to get answers. When I finally lost it and yelled at some poor woman who kept transferring me to the same full voice mail when I called each time, I finally learned that First Steps changed their phone number and not only didn't provide it to the public, but did not provide it to the people answering the phones within FSSA. THIS appears to be how they are trying to trim their budget. Apparently the fewer people that can contact them for services, the fewer services they have to provide. If they truly had children's interest in mind, they would make their services accessable. I have no idea what these changes will mean to me and my child, but I can tell you that without the services provided by First Steps, my children would face a much more difficult future.

          I understand that we all have to live within our means and that budget is important. But when I look at my budget, I try to trim expenses. I don't see how forcing providers to add another middle man can help my child or others. If the concern is therapist turning in papework late, then how are they getting paid? Are they paying for work before proof of having the work done? If the concern is communication, that's a lame excuse. From my experience, the therapists I work with are very open to communciating with me as a parent, my daycare provider and anyone else I need them to communicate with.

          Time to stop letting the bureaucrats make decisions they have no exepertise in. If Mitch Daniels wants to have a meeting to understand the effects on the children and families, sign me up!
        • Let's see
          After a long career in early intervention and also as a developmental preschool teacher, I thought I might just retire when we moved to Indiana in 1994. But I missed the work I loved so much that I became and independent developmental therapist (early intervention special education teacher) For the first several years I averaged almost 40,000/year,about what a first year teacher makes in the public school system. Except I got no health insurance and had to subtract my own taxes from that sum. Then the state cut our pay by six percent and have never given us a raise in 10 years. So now after this new pay cut and having to pay an agency to bill for me, something I have been doing all by myself for the last 12 years, I will be making about $16/hr less then I made in 1998. Remember also that I am paid nothing for my gas, the extra time I spend with families (they need support/education as much as the child needs therapy)and the hours I spend doing reports and team contact. I used to see 15 to 18 children/week, now I see around 10, it's become my retirement job. I keep doing it because I love it. I love feeling that I am doing a job that is really payback for the space I occupy on earth. Also, I know that I have a lot of experience and am very good a what I do. And so, I will continue doing this job until I can't get down on the floor anymore. BUT I will be earning about 22,000/year. That's less then I made as a first year teacher in 1972! That makes me feel pretty disrespected as a professional with great skills and lots of experience.
        • More BIG Govt Control !!
          Cost shifting is exactly what is happening here , as well as BIGGER govt (control over the people) butting in because people inside our govt always think they know much better than the REAL experts how to run things. This is absolutely inexcusable and disgraceful !
        • RE: Ignorance
          Thank-you to Tara, MBG, J,and Carol Krise for pointing out the ignorance of "frustrated provider's" statement. I suspect he/she really isn't a provider at all or he/she would be dealing with all the issues you point out. Again, if it truly was such a "gravy train" as they claim, I suspect First Steps would not already have a shortage of these providers. I know many parents and providers that have great suggestions for cutting costs and increasing revenue to maintain the program, but the state didn't ask and isn't listening. Sad!
        • annoyed at false info
          This is regarding "frustratred povider's" comment. I have also been doing this for 8+ years, full time and I have NEVER been able to bill an average of 24-35 hours per week. For many years we were capped at 25clients a week. With a full case load over 8 years I have averaged 16 billable hours per week. I do not see how it is possible for a person to average 35 clients per week, not if you are actaully spending your hour with each clients and traveling between and for those of us that do drive far between clients to serve those kiddos in underserved areas, ther is not enough time to see 35 in a week, which you would have to schedule more than that to be able to bill that many in a week, becasue we all know how often visits get cancelled, often times without even a courtsey phone call. So yes you are in the monority of porivders who think that these changes are beneficial to the program. Adding a middle man is rarely helpful.
          I am not looking forward to paying someone to do my billing, I am quite capable.
          I do feel fortunate that I have found an agency to work with that I like, but not all quality providers will be so lucky.
        • Providers cherry pick???
          The state level feels we(providers) are spoiled by a large amount of money and cherry picking our service areas. They cannot understand why we don't include the rural areas that are one to one and a half hours away to see possibly one child. They say they do it everyday!! My take on that is they are probably paid wages for a 9-5 day and what does it matter if they are driving or sitting at a desk? They get paid the same. WE DON'T!!! They dont get the number of unbillable hours we put in!!!!!!!For every billable hour I put in, there is about 1-2 hours un-billable. How do I arrive at that? I stay and talk with a family at the end of my session daily for 10 in to 30min, drive time is between 15-30 min each way, talk to other providers on team weekly-30 to 60 min, talk on phone to parents,call to talk with doctor, service coordinator, fax time, progress note time, eval and scoring time, etc!!Boy it just keeps making me more and more sick!I am shocked how little the SPOE (systems point of Entry) understands how much un-billable time independent providers put in!
        • Help Mitch be Pres.
          Way to go State of Indiana...Once again you have embarased me with your lack of enlightenment and foresight. Funds declining? Well, let's cut the programs for the most vulnerable (the disabled) where it will have the most impact (0-3 population) so that the EI system is less effective than it has been the past 12 years and so that the state has to PAY FOR MORE services when these kids are older!!!! Yea, that's it..We will put off paying the bill and when those kids are older and still have lots of deficits because they had inadequate early intervention due to cuts in 2010, we will just pay even MORE money and it will be LESS EFFECTIVE! That will make our world a much nicer place. After all, all of the latest Neuroscience research shows that the brain is not very plastic at these young ages...so who cares?????
        • First Steps Changes
          As a therapist with First Steps for over 17 years, I too am extremely frustrated with the new changes to the system. I understand the need for budget cuts and have no problem with that. However, asking a small business to give up their independence and another 10% of their income, is not free enterprise and seems illegal. I agree with Carol Krise - there are many checks and balances for overseeing therapists and their work. Mainly the families we serve - if they are unhappy with their services they can change therapists and complain to the state.

          One point that I think needs to be made is the fact that the 0-3 population - Early intervention has been researched and proven to help children with disabilities improve before they reach preschool and kindergarten age. THIS PROGRAM HELPS TO PREVENT CHILDREN FROM NEEDING FURTHER SERVICES IN PRESCHOOL AND KINDERGARTEN AND THROUGH 12TH GRADE THAT THE STATE PAYS FOR THROUGH OUR SCHOOL SYSTEMS. The state needs to look at the bigger picture of this program and the money it can save the state down the road.
        • Yes, check the facts
          Yes, we are allowed to be and in most cases still have to be self-employed to be a First Steps provider. We will be doing the same job for less pay--the only thing the Agency will be doing for us is billing (which is very simple) and supplying face-to-face therapy sheets.

          The current system DOES have a system of checks and balances for current providers. The SPOE is to be providing some oversight. The Service Coordinators are to be the one who makes sure that reports get in and to report those providers who don't get them in. There are also audits--by the SPOE or by FSSA. They did not do these regularly for many years as they should have been doing. The state wasn't utilizing the checks and balances that are in place.

          Also, the state does not communicate well. They do not have a training program for how to do the job--the paperwork part. There is an orientation program but it is more about the background and running of First Steps. There are some follow-up seminars that new providers have to take, but there is different information presented in those seminars. There is not consistent "how to" information on the First Steps web site, or presented in seminars. Rules are set and then published months later. Some rules have only been published once or twice in 14 years (in a quarterly publication--not in an ongoing new provider training seminar). Service Coordinators give differing information about "how to" and "have to."

          When I was audited, I had documentation to prove when some rules were established, yet the state still enforced those rules on me for work done previously to the date of publication of that rule. With the state worker saying, "I make the rules. I decide when the rules apply." So, you can see, there is much confusion about rules and regulation because the state doesn't do its job.

          I know of several people who have been audited and many of those audits were unfair. Even to the point of fraudulent. I proved that my audit was fraudulent, yet I was forced to settle unless I wanted to spend 10s of 1000s of dollars to fight through the court system. I decided that my life was worth more than that. The state did not involve their lawyers in the meetings regarding the audit due to the fact that I had already proven it was fraudulent. So, even if they use their checks and balances that are allowed, they are not fair--is that a true checks and balances then?

          Yes, we do make a nice hourly rate. But, that is ONLY for the time spent with the child. And full time is more like 20-hours a week. One has to make time for report writing, travel time, phone calls to other therapists, cleaning toys, therapy prep, the extra time spent on emails/texts/phone calls/in the home with parents, processing paperwork, filling out change requests, scheduling, rescheduling, and a few other things we do as a professional. Also, if we don't see the child, we don't get paid. So, with no-shows and cancellations, we are out the money. AND, most of use said that we were willing to take a pay decrease, but please just let us stay independent.

          I have formed a group of independent providers that meet monthly and have an email list to help each other to understand First Steps rules, regulations, change in rules and regulations, running a small business, and therapy ideas/help. We are not clueless as to how to be professional and do our job. (You are not the only one doing things right!!!)

          The state is NOT utilizing all funds available as revenue with this program. Dawn Downer is not doing her job. She is a state worker and is responsible to US, the taxpayer, to be a good steward of our money. She should be utilizing all private funds available--i.e., private insurance. The state does not correctly bill insurance companies. Dawn is stating that agencies will be better at billing insurance or helping the state bill insurance. She is requiring that the agencies attend training on billing insurance. There are trainings now offered and advertised through First Steps. Well, this was NEVER done before. There was no training for independents. We as professionals knew that incorrect codes were being used. We as professionals called Service Coordinators and Physicians to get correct codes. We knew families were being incorrectly billed for services due to the state not utilizing insurance billing correctly. Dawn sent a communication to families stating that the state does not have to bill insurance. That is probably true. But, that is a cope out. She is responsible to us the providers, to the families, to the taxpayers to make this system work.

          The state will not go to a "no program" status. Then Mitch Daniels would never make president--it would look too bad. But, for him to be able to say he balanced the budget--that is what is important to him. Unfortunately it is at the cost of small business and high standards that have been First Steps. I've always said, this is a good program because of the professionals out here going week after week to family's homes, not because of the state level workers.

          And, this change has been handled VERY unprofessionally and even probably illegally. Dawn and the other FSSA people have forgotten that they work for us. We have voiced our opinions and our opinions have been ignored. Dawn has given untruths and half-truths to the media and to senator's offices. The state has not returned many phone calls. The state does not know the whole transition and what the program will look like, they are just piecemealing this together as they go. It is obvious as they can't answer our questions or we get several different answers to the same question.

          So, yes, you are in the minority. And anyone that trusts FSSA/First Steps to make wise decisions and be fair is a fool.

          Sincerely, Carol Krise.

        • think about it people!
          To give perspective here, providers will still be allowed to have a small business under the new structure. The article is incorrect. It is a minimum of 10 therapists to be a network agency.

          The current program does NOT have a system of checks and balances for the 1,000+ independent contractors. There is no oversight. So yes, the new changes will provide "another layer" as someone mentioned. It will also provide much needed oversight so that ALL providers will follow proper procedures! As a provider for 10+ years, I have struggled with other providers who do not follow procedures. They never turn in reports, or their reports are ALWAYS late. Some are consistently late for appts or leave early. It puts the family/team in an awkward position because if the provider is independent, there is NO ONE who oversees their practice. Yes, there are billing and credentialing audits...but in 10+years, I have never had one. I know I'm not the only one.

          Also, I find it interesting that my fellow providers are crying "foul" about the $$ situation. Really?? What is your motive? Your own interests? Where else are we going to work and make the $$ that we make now as independents?
          PT = 90.40 per hour
          OT = 86.56 per hour
          SLP = 77.40 per hour
          DT = 62.76 per hour

          As a provider working full-time, we probably bill an avg of 25-35 hrs per week. On the low end, for PT, OT, and ST billing 25 hrs/wk, that means we are billing at least $100,000 per year. It is not reasonable to think that we would ever make that in another setting (hospital, rehab, nursing home, etc.). The gravy train is over people, get over it. Stop using families and children as your scape goat.

          The bottom line as I understand it is that the state must balance the budget for First Steps. If not, the program is in jeopardy and NO services will be available for families! Early Intervention (Part C) is NOT a requirement for the state. States can "opt-in" or "opt-out". Then, if the state opts in, there are certain federal/OSEP requirements the state must meet.

          Our provider community needs to realize that our administration is working toward a system of accountability and fiscal responsibility. We need a system that is sustainable for today and tomorrow. I really wish my fellow providers would stop worrying about their own interests and consider the alternative - NO program!

          p.s. I know I am the minority amongst my peers, so I chose to not disclose my name. However, check the facts, they are real.
          • Ridiculous
            LOVE how the state hasn't even contacted independent providers DIRECTLY to let them know what changes ARE taken place! Changing criteria for qualifications of DTS. Not clarifying WHO will be GRANDFATHERED in. Leaving EVERYONE (therapists, FS families) in limbo. Most feeling insecure with their job future.
            After the first of the year, the state will be wondering why they don't have enough qualified therapists to take care of all of the children that qualify.

            The state needs to get their head out of their butt and problem solve better!

            I'll be the first to say "I told you so" in a couple of months when the system is completely messed up because of the states uneducated decisions.
          • GOP cons the Public
            Obviously Mitch is getting kickbacks in donations from the "agencies". Another cronie who is line to get a cut of public funding under some trumph up claim of better but reduced service.

            And the GOP and Mitch is suppose to be in favor of small business creation -- Unless there is a company that gives money to the GOP then he is Anti-small business. Goes to show that the GOP talks one thing but in reality is all about money in someone else's pocket - NOT IN THE INTEREST OF THE PEOPLE.


          • Illegal
            What I have come to understand from attorneys is that due process was not followed with these changes. Does anyone see a problem with this?
          • Common Sense
            Can someone please bring this to Mitch Daniels attention? I am sure he would be interested in cutting the stateâ??s budget even more while providing a better program/system to its residence. Who is coming up with these idiotic ideas?
          • Confused
            So if I understand this correctly, First Steps is requiring therapists to work for an agency. First steps will pay the agency who will take a cut, then pay the therapist. The $2 million savings is achieved by cutting reimbursement by 5%. This savings happens regardless, but now the independent has to take another 5-10% cut plus possibly providing less service to the child. Ultimately hurting the program. Can we wake up here? How did a THIS state administration approve this? From the speeches I have heard from Mitch Daniels, this is against everything he fights for. Letâ??s count them. 1. More government control/less privatization 2. Increase the state budget for a less efficient system (Letâ??s think about this. Is there a way to save even more by not paying a middle man???? Again letâ??s wake up here) 3. Paying less money to the best and experienced workers 4. Increase in Indianaâ??s Brain Drain. The best and brightest will be forced out and possibly leave the state. Perfect example of the stateâ??s problem.
          • Communism
            Quote from Dawn Downer in the article â??I hope most of these providers can also look at the greater good,â?? Greater Goodâ?¦ Sound like anyone? Chavez, Mao, Stalin, etc. Dictatorship anyone?
          • Our ideas not considered
            As a therapist who serves the indy area I would like to say that the therapists that work to serve 0-3 population are aware that everyone has to live within a budget. We would have liked some of our cost saving ideas at least looked at. We understand pay cuts maybe necessary in these times, but really would have liked to have had our voices heard and been given the opportunity to maintain our independent status. Instead, we have many rules and regulations rammed through without any consideration given to the ideas of the people who actually perform the service. The families also have to deal with a system that will be less flexible and give them less options for their child. In the end, the children and their families lose, along with the therapists, in a proposed system that takes choices away from us all.
          • Shame on the State
            I'm a First Steps provider who has been in the First Steps system for over 12 years. To date, this has been the most unfortunate (and disorganized) change the state has placed upon us as providers. They did not ask for input or give the providers an opportunity to be part of the process for the good of the program. They just made drastic changes that will put our most vulnerable population (birth - 3) at a greater risk. This is a financial reimbursement problem - not a clinical problem. This change will contribute to many experienced therapists leaving the program (I know many who already have), and force the families to choose an agency with therapists who do not have the expertise in an area that their child requires. It's like choose a hospital but not your surgeon!! The people who should be accountable for the First Steps financial problem are those responsible for submitting claims with correct diagnostic codes. We are a developmental model, forced to work under medical guidelines. Claims are being denied due to this problem. Forcing therapists to do the same job, for less money and allowing the agencies to profit off our work is ridiculous. Shame on the State of Indiana for allowing our birth - 3 population fall through the cracks!!
          • Still Furious
            The article did not tell that we already took a 6% pay cut a few years back. And now a 5%. Then when we go to an agency, it will be another 10-25% cut.
            So, are the state workers who pretend to run First Steps also going to take a 5% pay cut on December 1st?
          • Furious
            In the article Dawn commented: their concerns should not take precedence over what she sees as best for children in the program.
            Really, Dawn Downer? We should trust you? Remind us, what is your degree in? What experience do you have with early childhood? What kind of therapy degree do you have? What school did you go to get your teaching/therapy/early childhood degree?
            Yep, I thought so...Aren't you an AVIATION ENGINEER? How does that relate?
            Nope, I don't trust you. My concerns are very warranted when someone like you is leading the way.
          • Save $$
            If understanding this, money will be saved by opening offices, hiring staff, paying benefits of vacation/health insurance? Hmmm, sounds like magic fairy dust has been sprinkled. This of course doesn't count the potential decline in services. Remember the IBM experiement? Let's hope the dust settles and common sense prevails. $2mil/year ... makes me wonder.
          • First Steps and agencies
            Requiring a family to choose an agency which may or may not have the best therapists for their child is akin to requiring a family to choose a hospital that may or may not have the appropriate surgeon for their child. Where's the cost savings? Where is the logic?
          • Tsk Tsk

            FSSA should be a sore spot for the gov't and gov'ner.

            There's nothing like having a bunch of suits (ties cut off oxygen to the brain) walk in with nice, glossy reports & plans, then screwing the pooch.

            I've said before and I'll say it again:

            "it ain't that tough"

            I'm rather enamored of Jim Collin's "From Good to Great". ca. 41, he mentions, "find the right people on the bus, then determine what seats they belong in."

            In Indiana, it means finding someone with "10 years of this, 4 years of that, this that and the other thing." Or in terms of human languages, you can spend a long, long time for someone who has had ten years of Catalan when you can get someone who has two years of Latin, 4 years of Spanish, 3 years of Spanish.

            IOW, you have to find people who can shift gears and pick up what's going on without a lot of misfires.

            It's not that hard.

            What's funny (in a bad way) is incomplete software was installed IN 1/3 OF THE OFFICES OF THE STATE. Is that supposed to make someone feel like the entire project is 1/3 of the way done?

            It just isn't that hard.

            Maybe he needs to privatize it from day zero...and keep people who don't rely upon glossy reports to stay off the bus.

            Get an audience with the Gov'r, people of different levels of FSSA, (workers) people in the field, recipients from various parts of the state, people who have an easy time handling what they have to deal with the status quo, some of the people who absolutely would do anything to make it work.

            Lots of questions to/from, lots of notes, etc. etc etc.
          • cuts
            What this story dones' tell you, is on top of the 5% cut to the providers, these agencies are taking 15-20% cut of the providers pay to offset their cost for billing, training, and overhead.

            The state is giving lip service to the real needs of these kids and sacrificing quality for saving money. If the state was really concerned about improving communication, they would reimburse providers for inter-provider communication and it would happen. Since when does adding a middle man improve quality and communication? Seriously?

            If the state listened to anyone before they enacted this, it was the owners of the new agencies...they will make a killer profit now.

            Sure, the state will be able to lay off some of their accounting staff and pay a fewer # of providers for first steps services, but the agencies will have to hire accountants on their side and pass along the expenses. This is cost shifting 101...at the sacrifice of the kids.

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