Autism Review

Emergency action is necessary for the preservation of the public health and general welfare to immediately conform the Commissioner's regulations to chapter 460 of the Laws of 2011, and thereby ensure that such regulations are in effect on February 14, 2012, the effective date of such law, to implement the new practice and supervision provisions consistent with statutory requirements, EXCEPT FOR WHERE IT MESSES UP OUR ABILITY TO GET MEDICAID REIMBURSEMENT, IN WHICH CASE NOTHING IS A GREATER EMERGENCY THAN OUR ABILITY TO RECEIVE THOSE FUNDS. (italics mine)

I recall being a newbie occupational therapist and having a keen sense of "having to put my time in." It is probably a broad cultural value passed to me first from my family. My Dad was a hard working person who I saw go to work every day and sometimes even every night when he was assigned an evening shift.

When I graduated from college I gravitated toward home care and consultative occupational therapy; the freedom and responsibility of these settings matched my interests and work style. Since I was a newbie and trying to work for home care agencies all of the preferred geographic areas were taken by more seasoned occupational therapists. That left me with assignments in far-flung areas where I had to drive up to an hour to get the the patient's home. I figured that I would accept these cases and then after some time I would be offered cases that were not as far away.

So, during this time in my career when I was driving from Buffalo to Farnham and North Collins, dreaming of closer assignments, I met Peter Talty.

Peter was one of those 'more seasoned' OTs who I imagined I was competing against for favorable home care referrals. He called on the recommendation of Kent Tigges who was a mutual friend and said to me, "So I hear you are interested in some work and Kent tells me that I should call you!"

I already knew who Peter was although I never met him - and I was nervous and excited that he would call and offer me a job! Now being a newbie and most certainly not being in a position to turn away work and being flattered to have Peter Talty call me and definitely wanting to show my best for my mentor Kent I listened to myself reply, "Sure... definitely!" even before asking for any other details.

I'll never forget meeting Peter in person for the first time and I will never forget the first question I asked: "So... where did I agree to work and what kind of work will I be doing???"

Peter didn't hesitate a second in his response - he delivered the news to me in the straightest of terms. He deadpanned, "You know when you are driving along a major road like the Thruway and there is an exit for a town you never heard of? Then you look over and all you see is trees and maybe a gas station sign? You might wonder what is over there if you took that Thruway exit. That is where we are going to go!!!"

I noticed that he said "we" and that surprised me a little - after all, most "seasoned" occupational therapists only worked in places that were geographically close to their homes. I quickly learned that although Peter was very experienced he was definitely not like "most" therapists.

Although Peter lived near the Buffalo area he went with me to set up and deliver occupational therapy services in very distant places all over Western NY. We went to nursing homes in Salamanca and Machias. We went to community rehabilitation programs in Olean. We went to a residential program for children who had developmental disabilities in Bradford, PA. I will also never forget how Peter gave me directions to find these places: "Keep driving down this road and you will see a place called 'The Cow Palace' on your right. Keep on going and take the right fork in the road after that - but it won't have a street sign." Peter's directions were legendary.

While thousands and thousands of miles ticked off my odometer I never minded it at all. Peter was an amazing role model and I quickly dropped my preconceived notions of how far experienced OTs should have to travel for work. Peter Talty went the extra mile.

He didn't just go the extra mile in physical distance - he did the same for me, for the COTAs we supervised, and for all those patients including every child who had an IEP along the old Route 17 between Randolph and Belmont. In places where there was no occupational therapy, in places where occupational therapy needed to be, Peter Talty made occupational therapy happen.

I also recall Peter's phone call to me asking if I was interested in teaching some lab sections at a college. By that time I knew enough to ask "where is this college where we will be going??" Of course he was referring to Keuka College - a two hour drive for us both - but it was another tremendous opportunity to watch Peter 'go the extra mile' in so many ways for hundreds of occupational therapy students over the years.

A year or so ago Peter called me and wanted to spend some time in my private practice. Watching him work again was another amazing reminder of what he brought to patients, how he listened to their stories, and most importantly how he helped them move forward with their own recovery.

Peter Talty is retiring from Keuka College this year and I can think of no better way of honoring him than telling this story of how much good you can create when you are willing to 'go the extra mile' as an occupational therapist.

Whenever I drive along a road and wonder what is over the treeline I think of how important it is to care. I also remember that Peter showed me that you also have to care enough to actually put yourself into action. Sometimes the people who need us the most will be in places where we haven't been before and where we never imagined ourselves being. His example is one I will always aspire to.

Earlier this week I noticed a large uptick in Google searches regarding early intervention that were landing on this blog so I started wondering what was going on. Turns out that there was a NYS Association of Counties meeting this week and the Department of Health gave a powerpoint presentation about the Governor's proposal. Copies of the powerpoint started to make their way around the State - and that got people doing some Internet searches for more information. Here is a link to the presentation for those who have not been able to see it yet.

The powerpoint doesn't offer information that is materially different than what is already listed in the proposed budget but it is in a more readable format.

The largest issues proposed include:
1. Providers will be approved through the Department of Health and won't have contracts with local municipalities.
2. There must be an arms length relationship between service coordinators, evaluators, and service providers.
3. Providers will be required to establish and maintain contracts or agreements with a sufficient number of insurers, including Medicaid and CHP.
4. Providers will have to use the State's Fiscal Agent to bill third party payors.
5. All of this will be achieved by a mandate on insurance companies requiring them to coordinate through the State Fiscal Agent to pay for EI services.

Details that are still a little unclear include how the rate will be negotiated. Currently, there is no alignment between EI rates paid by municipalities, rates paid by insurance companies, and the Medicaid rates. It is unclear whether or not the rates will change based on the information released so far. The current plan calls for providers to continue providing services whether or not they have been reimbursed - so there will need to be some clarity so providers understand the rule systems they are being asked to operate under for reimbursement.

It is likely that this will drive some providers out of the system and that will likely create delays in service provision. That means that private therapies, at least for families that have those resources, will likely replace the EI system as the de facto methodology for children receiving services. It is another form of indirect cost sharing, and is probably intentional.

Stay tuned for ongoing analysis.

My sensitivity for the challenges of being an Academic Fieldwork Coordinator runs quite deep; I held that position at a college for three years and experienced the difficulty with finding student placements. There never seems to be enough fieldwork placements, there are challenges with finding places that will provide a quality experience for the student, and although there have been efforts to incentivize practitioners to take students that does not overcome the practical obstacles.

The repeating theme that the occupational therapy profession is not yet grasping is that there has to be some kind of understanding that services provided by students are not the same as services that are provided by licensed professionals. This has been a recurring theme for Medicare reimbursement of services provided by students. Fieldwork educators are very familiar with AOTA's efforts to establish clarity in these rules.

There is a parallel pushback against allowing student provided services to be reimbursed in the Medicaid system. In NY State there are restrictive rules about OT students providing Medicaid services to children. This has a large impact on practitioners willingness to accept students.

Large systems like Medicare and Medicaid are obviously motivated by creating high standards that promote public trust. If public dollars are going to pay for skilled services - then the services need to be skilled. This is understandable.

Now we are seeing new legislative perspective on this issue. While NY State tightens up regulation of OTA practice this has opened up the issue of student supervision as well. Current proposed regulations are getting much more restrictive for students - and now it is being proposed that OTA students can only be supervised by OTs and not OTAs. Furthermore, the degree of supervision that is being proposed in NY for a person who has a limited permit is more restrictive than what is generally being practiced for OT students - and there is no logic in the position that any student requires LESS supervision than someone with a limited permit. This means that if the current proposals for supervision of people who have limited permits is applied downward to students - there are going to be huge problems with models of 'non-traditional' fieldwork education. Also, removing OTAs from the equation and not allowing them to supervise OTA students will place a tremendous pressure on OTA fieldwork opportunities.

The pickle that NY State is in gets even worse - part of the proposed regs allows 'physicians' (which are not statutorily defined) to provide supervision of OTAs. This is a rather large concern because it might remove OTs from the loop and encourage optometrists or foot doctors (much less regular MDs) to hire OTAs in their offices, provide 'supervision,' and begin billing for OT services. Of course most people oppose this, but the State Board of OT comeback is 'you can't be AGAINST physician supervision and be FOR supervision by non-OTs for 'non traditional' fieldwork at the same time.

The concept of 'non traditional fieldwork' is interesting but we have not had enough discussion that relates to whether or not it 'constitutes OT' or is 'just something an OT can do with their education.' These are important legal distinctions. This also raises the issue of whether or not these 'non traditional' sites provide appropriate preparedness for taking the certification examination and practicing OT. Apparently, if we don't tackle this issue ourselves we will see regulatory boards step in like in NY.

My very strong suggestion to AOTA and ACOTE is to PUT ON THE BRAKES when talking about 'non traditional fieldwork.' The notion that "one-to-one supervision, a hallmark of traditional placement models, is replaced by alternative supervision practices such as collaborative learning or distance supervision" (Hanson, 2011) is starting to look like an idea that might have some pretty big legal problems associated with it in some contexts.

The current crisis in NY should be examined and studied CLOSELY by all other states. Opening up a practice act is a can of worms, and now we are seeing some major unintended consequences. There were issues to address in NY but this is an amazing study in why it is important to open up ONE ISSUE AT A TIME - or at least to have enough eyes on the ball when multiple issues are opened that unintended consequences are held to a minimum.


Reference:
(links in text)

Hanson, D. (2011, Nov.14) Expanding practice borders: The value of nontraditional fieldwork models, OT Practice, pp.6-8.

Early intervention and preschool services to children who have disabilities will be scrutinized heavily in the upcoming year and many reforms are being discussed. This summary is a general outline of some of the salient drivers that are impacting reform efforts in New York State.

I strongly recommend starting your reading with the Reforming Mandates, Reducing Costs report that was written by the New York State Association of Counties. This report was submitted to the Medicaid Redesign Team last year to provide input about the unsustainable increasing costs of these programs.

Mandated Medicaid costs are crippling County budgets, and have been for many years. Most recently the State entered into a settlement agreement with the Federal Government often referred to as the State Plan Amendment. This settlement is the contract between New York State and Federal government whereby the State agrees to administer the Medicaid program in accordance with Federal law and policy. This agreement imposed backdated requirements that made it virtually impossible for Counties to receive payments for services that should have been reimbursable as they were compliant with rules in place at the time. This placed a very large strain on this particular component of Medicaid reimbursements to Counties.

Recently enacted property tax caps complicate the situation. You don't need to be an accountant or the County Comptroller to understand that rising costs, lack of reimbursements, and constricted income all spell a recipe for disaster. In short, Counties are being crippled by these programs.

County budgeting staff are at their wits end, and that is why you see proposals from Counties like removing them from the fiscal, contractual and programmatic responsibilities of the program, limiting eligibility to individuals that have greater delays in development, requiring some family financial participation based on income, increasing the County role in developing and writing Individual Education Plans, centralizing organization to the County as opposed to the district level, requiring parent participation for non-working parents, and eliminating contracting/fee for service arrangements because of the inherent conflict of interest with the current system. All of these and more recommendations were made to the Medicaid Redesign Team.

Some of these recommendations are more reasonable than others, but the point in reading this report is that it will help people understand the desperation of Counties.

Providers and parents may not understand these dynamics as well as they need too - I frequently hear calls to contact the NYS Department of Health, or to lobby the school districts, or to make noise in general to their legislators about how these services can not be touched. All of these call to action are potentially misguided. The ability to understand the problem starts at the level of the Counties and their Medicaid budgets and an analysis of the unsustainable growth of these programs and the inability to meet these costs within the current and expected fiscal environments.

You will not help this situation by yelling at your CPSE Chairperson. You have to start with your County legislators and understanding the broad dilemma that they are in.

Readers here are being informed that Governor Cuomo HEARS the Counties and UNDERSTANDS the dilemma. He released his Executive Budget yesterday that calls for some dramatic reform to how these systems are administrated. This WILL have a large impact on service eligibility and service provision - it WILL NOT just be a switch to billing a new entity.

Future posts here will cover the inability to NY State to effectively administrate EI billing, inability to recoup revenues, and inability to effective coordinate via the well-intentioned but very broken NYEIS system, the Counties' calls to the Governor to act on these problems, the rock and hard place of Counties with respect to the property tax cap, and what the Governor's proposals will mean for actual service provision.

This will also include a deep exploration of our own social and cultural values. The large question to answer is 'What is society's responsibilities for these programs.' It will be an interesting ride for the next couple of years as all this plays out.

Stay tuned for ongoing analysis.

I have a longstanding interest in Systems and their impact on our ability to care for people. In 2005 (I can't believe I have been blogging that long) I wrote a blog entry about foster care policy and its impact on occupational therapy.

I try not to get outraged on a daily basis because it makes it a little challenging to maintain focus. If you think about foster care too much though it is hard not to get a little upset.

These Systems are populated by well intentioned and kind people who have to do yeoman's work to make the System run. The problem is not with the well intentioned and kind people who work within these Systems - the problem is with the System creators who have set up a structure that in my opinion fails to meet the needs of the people being served.

That's not so good.

Mental health care Systems are notoriously poorly designed; we have systemic problems like homelessness and poor care coordination and uneven access to care. The Systems are so poor that the American Academy of Pediatrics recommended a model of school-based mental health service delivery. I like the concept, but I am noticing more and more that school systems are ill-equipped to handle mental health needs of children.

The primary point of difficulty that schools have with this kind of service delivery is in the MODEL that is used for defining problems. As an example, an Intake History that I read recently started off describing all of the problem behaviors of a child including lying, cheating, stealing, profanity, attention difficulties, poor ADL compliance, and aggression. Somewhere in the middle of the second page of the Intake was a section with diagnostic information, and it was left blank because the information was not available at the time the Intake was completed. Digging through the educational file, I eventually learned the following:

1. Diagnosis of Dysthymic Disorder, early onset
2. Parental abandonment
3. Possible sexual abuse
4. Multiple foster home placements

This child's story is sordid and would bring most people to tears.

I am stuck because I am trying to understand how we have created a System where the well intentioned people have no MODEL for understanding the nature of the problem. They are just educators, or perhaps people with a B.S. in psychology or a generic human services degree - and they start off with defining the problem as lying, cheating, stealing, etc. etc.

How does that happen?

The System is populated with clinical social workers and an occasional consulting psychiatrist and even an occasional occupational therapist - but the NON-CLINICAL MODEL that is perpetuated causes people to start identifying the problem as the presenting behavior, or by how the child is functioning in the context of the school. Somewhere along the line we have forgotten that this is a child whose parents have abandoned her who has been to multiple foster home placements and repeatedly raped.

If these facts are true, how horrible is it that we have created a System that places the PROBLEM on the middle of the second page (where it was unceremoniously left blank) and only ambitious people who dig through old records are able to find a psychiatric report that lists the REAL PROBLEM??!

To make matters worse we then relegate the care of these abused children to people who do not have enough input and guidance from mental health clinicians. I really don't know where all the mental health clinicians are. I can speak for my field of occupational therapy - only 2% of OT practitioners even work in mental health settings. Occupational therapy has abandoned mental health and moved on to other pastures. Only now is our professional association starting to make some much needed moves to re-insert the profession back into the mental health care Systems.

I suspect that this issue of abandonment of mental health is not unique to OT. Every professional who still has involvement in these Systems has a unique opportunity to educate the Systems on the value of using a more clinical model for the purpose of FRAMING PROBLEMS.

Eventually these Systems need to be absolutely torn down and replaced. They are broken and we need to stop pouring money and misplaced effort on propping up failure.

Unless we are intent on continuing to fail.

I wondered this morning how much writing I have done on various OT message boards and I started thinking that an awful lot of my opinions are probably documented all over the Internet. I visited the forums on the AOTA website and found the equivalent of over 40 single spaced pages of my writing! Then I thought it might be interesting to see what motivated me to post on professional forums this year. Here is a summary of one interesting forum conversation:

The Social Justice Debates

Early this year there was a motion to rescind part of newly adopted AOTA ethics statements; the concern was that they unnecessarily referenced social justice concepts and that the existing ethics statements already covered that conceptual material and did so without politically charged terms like 'social justice.' The new ethics documents includes:

SOCIAL JUSTICE
Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.

Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp & Childress, 2009). In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation in society (Braveman & Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.

Occupational therapy personnel shall
A. Uphold the profession’s altruistic responsibilities to help ensure the common good.
B. Take responsibility for educating the public and society about the value of occupational therapy services in promoting health and wellness and reducing the impact of disease and disability.
C. Make every effort to promote activities that benefit the health status of the community.
D. Advocate for just and fair treatment for all patients, clients, employees, and colleagues, and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession.
E. Make efforts to advocate for recipients of occupational therapy services to obtain needed services through available means.
F. Provide services that reflect an understanding of how occupational therapy service delivery can be affected by factors such as economic status, age, ethnicity, race, geography, disability, marital status, sexual orientation, gender, gender identity, religion, culture, and political affiliation.
G. Consider offering pro bono (“for the good”) or reduced-fee occupational therapy services for selected individuals when consistent with guidelines of the employer, third-party payer, and/or government agency.

My own concern was with the statements "to abide by the highest standards of social justice" and "provide services that reflect and understanding of how OT service delivery can be affected by factors such as..." Here the politically co-opted definition and political twist that is taken with the term 'social justice' was challenging because of the associated statements about distributive justice which is politically charged. Additionally, there seems to be a suggestion that there is de facto impact on service delivery because of certain issues like age, ethnicity, race, etc., and many people object to that assertion. There is no doubt that prejudices exist, but it is not correct to state that there is de facto impact.

My concern was also related to how 'social justice' was being defined in the current American political context. I tried to compare worldwide Catholic social justice definitions to American social justice definitions. Context and degree seem to be overarching factors when it comes to definitions of social justice - for example, social justice from the perspective of a person in a developing country must be very different than social justice in the United States (which has incredible wealth and where even those who are very poor have their basic needs met).

Also, a core concept of Catholic social justice is in how it is practiced - no bigger than is necessary and no smaller than is appropriate.

Anyway, what I am saying is that I understand the Catholic position of social justice because it is a world-wide religion and the concept is being applied to a very broad spectrum of human existence.

That is all very different than the way that the term is being used in the United States as a redistributive economic policy.

I don't think that the OT professions needs to avoid issues that are politically charged, but it does not seem unreasonable to have a core value of inclusiveness so that we are not disenfranchising our membership - and there were some people who were uncomfortable with including this language in the ethics documents. I don't believe it is unfair to ask the appropriate contextual question of ''What does social justice really mean in the AOTA documents' and if it is such a core concept to our ethics - then why is it just appearing now?

This really was not a new concept for people who read here - I covered this material in depth previously.

The larger issue I was driving at in the conversations was "what constitutes OT practice and how do ethics aspirations suggest us into practice areas or into practice interventions that are beyond our mainstream." In many ways that makes them beyond pragmatic use to many practitioners.

I think that people can use their OT skills in many ways - but that does not necessarily make the interventions occupational therapy - even though some people are calling it that or perhaps want it to be.

I have no objection to giving recognition or praise to efforts that further people's health and participation - even when those efforts are informed by occupational science and are not falling within the mainstream of occupational therapy practice.

My concern is that sometimes it seems like we spend a lot of time in this profession playing in the stratosphere. Lofty ideals are fun, but the atmosphere is pretty thin - and sometimes it is nice to get your feet planted back on the ground again.

I believe that we will serve our profession best if our ideals and ethical aspirations have application to the everyday concerns of practitioners. If our ideals and ethics only help us populate an academic playground to see how many different ways we can apply our concepts then I fear that we will have created a great academic discipline - but one that has very little traction in everyday practice.

As a bottom line concern, AOTA ethics documents are included in some state license laws. That means that failure to abide by generic aspirational and potentially vague language about social justice in ethics documents might cause someone to be in jeopardy with their state license. That's not so good.

I did not believe that there was a need to include ambiguous social justice terminology to maintain our consistency of belief that people who have disabilities should receive services. The proposed motion to remove the politically charged terminology rather clearly outlined that nothing is lost by removing the social justice terminology, and instead the objective is to remove ambiguity that is associated with the term.

I greatly appreciated the distinctions that were argued between political social justice and ethical social justice in those forums - but the fact remains that based on a reading of the current ethics statement and based on a reading of our literature that there has not been such a distinction made between these different iterations of social justice. In fact - the two have been blurred throughout all the conversations as well as in the literature.

It was an interesting debate. The Motion to remove the language failed. So now I will continue the 'social justice watch' to see if any of this ended up having any notable and pragmatic impact on practice.

Jimmy was especially active and his mom was having a really difficult time keeping him occupied while she filled out his intake paperwork. His mom was a little frazzled as Jimmy darted around the room, jumped onto the chairs, pulled on the curtains (pulling them off the rod!), and banged on the windows. I intervened at the window banging for safety reasons and as I gently redirected Jimmy he lunged for his mom's coffee, and with a spray of cappuchino across the carpeted waiting room he finally paused.

"Oops," he said, as his mom gave him The Stare. Jimmy froze.

Mom froze too, and after surveying the mess she excused herself to the bathroom. I stayed with Jimmy who suddenly realized he was supposed to be sitting quietly.

Mom returned with some paper towels. The unfinished paperwork sat on the chair, and she cried as she dabbed at the rug. Jimmy knew enough to stare straight ahead at the toy on the child sized table and play quietly.

His mom was upset about the rug and worried that it would leave a stain. "I just don't know what to do!" she said between sobs. "I can't even take him somewhere to get help without it being a disaster."

I really didn't care about the rug because it can be cleaned. Also, cappuchino is relatively benign when I think about all the possible things that can get spilled onto a floor. "It's really ok," I said, attempting to reassure Jimmy's mom. She couldn't hear me and asked for some cleanser.

Soap is an emulsifier because it can take a substance like cappuchino and disperse it into another liquid, like water. Soap micelles have long hydrocarbon chains that help isolate oils or grime so they can be 'cleaned' or 'removed.'

I was thinking that maybe the paperwork was more important than the cleanser and that maybe for the short term the water would be enough to provide a diluted mixture to blot up and reabsorb the coffee into the paper towels. That wasn't enough for the mom though. She wanted some cleanser.

I watched the mom scrub and scrub at the floor, and I figured that is what she did with Jimmy too. I imagined her taking Jimmy against a washboard and scrubbing with all of her might. I bet she tried everything she could so that she could remove the behavioral difficulties that interfered with his participation in school.

You can scrub all day sometimes, and it just isn't enough.

Foaming agents are added to detergent products because somewhere along the line of history people started associating soap bubbles with ACTION. The bubbles might help some, but they aren't really required for the emulsification process. That's my very basic understanding of the chemistry of how this stuff works anyway. The mom wanted ACTION. She wanted to see her scrubbing effort make bubbles. Bubbles meant the rug was getting cleaned.

Maybe bubbles would mean that Jimmy's behavior could improve too, if only we were scrubbing hard enough in the right direction and with the right effort.

I found some rug cleaner and dabbed it into the carpet as I knelt next to mom and handed her a scrub brush. I grabbed a second brush and went to work on the carpet.

"I bet we can get that out no problem," I said hopefully as I scrubbed and scrubbed. Jimmy's mom smiled.

Proposed changes to early intervention reimbursements have been temporarily shelved. Today Brad Hutton, Director of the NY State Early Intervention Program, sent out an email stating:

The Department has removed from this regulatory package the changes to the payment of home and community-based and facility-based visits. The Department remains committed to continued examination of the EIP reimbursement methodology and intends to have more discussion about this and other proposals with its Reimbursement Advisory Panel in the coming months.

I know that a lot of people are very happy about this, but it is important that we consider all of the events that led up to this recent decision.

As I have discussed here frequently in the past there is no question that there is need to revamp billing for this program to help support collection of payments from insurance plans. The problem is that we just witnessed and experienced an extraordinarily irresponsible and haphazard attempt to fix the problem. In fact, in attempting to 'fix' the problem, the direct actions of the Early Intervention Program administrators have reduced the numbers of providers who are still willing to work with the program and there have been program closings based in part on uncertainty that was created because of real and proposed cuts.

I know many therapists who left pediatric positions, I watched programs close, and I have listened to and participated in the worried conversations of therapists who were left wondering if they would even have a program to work in. I have directly observed the creation of waiting lists for services and watched families opt for private therapy because they didn't want to wait for the EIP or they were unhappy with the fact that experienced therapists were leaving the EIP. There has been significant damage already done - and NOTHING has been done to fix the underlying administrative problems with insurance billing. Instead, we have seen the NYS government legislate looser standards so that the EIP has a better opportunity to collect payments. In other words, the government has been unable to manage with efficient operations so they changed the billing rules for themselves.

And now are providers going to feel better about this email from Mr. Hutton? What is it that people are supposed to get from this? OH NEVER MIND! WE WERE JUST KIDDING ABOUT THOSE CHANGES. SORRY THAT KIDS DON'T HAVE ACCESS TO SERVICES LIKE THEY DID BEFORE. SORRY YOU QUIT YOUR JOBS. SORRY THAT YOU CLOSED YOUR AGENCY. SORRY THAT I BLEW THIS WHOLE THING UP.

How will this irresponsible email promote a sense of stability in the program? Based on past history, why would anyone trust the EIP? This will not cause agencies to have confidence to hire therapists and the waiting lists will likely continue.

I strongly encourage Governor Cuomo to appoint EIP administrators who have experience in the real world of EIP service provision. There are many private EIP agency directors who would have a better grip on the problems facing the program and how to introduce reform in a responsible manner. No one is served by whimsical flip-flopping, publication and retraction of proposed industry-changing regs, and an apparent inability to understand the impacts that these actions have on the program and most importantly on the families who depend on the program.

Also, our Governor needs to develop an improved system of regulatory reform review. NY State had this in concept with the Governor's Office of Regulatory Reform that was established under Pataki and subsequently dismantled under Patterson and Cuomo. Although not all aspects of this program were as successful as others, in concept it provided a mechanism of regulatory review that may have prevented the Early Intervention Program regulatory debacle. These governmental entities need to engage in real outreach to the constituents BEFORE regulations are proposed. That would go a long way to promoting a reality check when new regulations are considered.

Regulations have an impact on families and children who receive services from these programs, and they have an impact on the businesses in this state that are set up to deliver these services. Someone seems to have forgotten this fact.

We had a program that had funding challenges, and now we have a program that has funding challenges and a seriously demoralized workforce that has no sense of stability. It is shameful stewardship of this very important program, and New York citizens deserve much better.