LIMITS

Everything must be limited, even doing good.

Over the years that my organization has been operating, we have added a variety of special populations to the ones we already served. The common denominator of all of these special populations is that they include people with some of the most serious and complex challenges.

At the turn of the twenty-first century, an opportunity to take over the caseload from a small agency presented itself. This agency provided behavioral health services primarily to children with severe autism. The seriousness and complexity of the challenges these children presented made this opportunity one that I was eager to take.

Several years later, another much larger agency was in the process of going out of business. They too served children with severe autism as well as children with other serious and complex challenges. This too seemed to be an opportunity that was very compatible with our mission, and our children and families services quadrupled overnight.

For about a year and one-half after we took over the caseload from this agency, we were able to break-even or make a very small profit on these services. The third year after the takeover proved to be very difficult. The most frequent service we were providing to children and families had a reimbursement rate that had not increased in many, many years. Although the rate had been generous at the time it was introduced, inflation had eroded the buying power of the rate, and we began to lose money on this service. These financial problems increased as managed care organizations took over the responsibility for paying for these services. In some cases the managed care organizations decreased the already inadequate reimbursement rate. In all cases, they became more and more conservative in their reimbursement rules. Many services that we delivered in good faith fully expecting to be reimbursed were denied completely by the managed care organizations for a variety of reasons. Our losses accelerated.

I loved providing these services to children for a variety of reasons. First, providing these services was fully compatible with our mission to help people with the most serious and complex challenges live a better life. Second, the good that we could accomplish by providing these services in many cases far exceeded the good that we could accomplish by serving other special populations. Our services to adults with severe mental retardation and behavioral challenges, for example, were highly regarded and we were able to give many people a much better life by providing them. Still, there were significant limits regarding how much we could change the underlying deficits these adults had. Serving children with severe and complex autism or other diagnoses gave us the opportunity to change their development while they were still malleable and subject to change. The good we accomplished with these services seemed to be even greater than the good we accomplished by providing services to other special populations.

As our annual losses on these services grew, I was faced with an increasing problem. Providing these services was good. Providing these services despite incurring significant financial losses was a greater good. But what was the limit? How much should I lose before closing down or at least significantly downsizing these losses? Because we were financially successful in other areas, my response for several years was "a lot!"

After losing millions of dollars on these services, I was forced to say, "Enough!" I still valued these services based on all the good they accomplished. I just could no longer justify incurring the accelerating losses. We had come to the point that these losses jeopardized the financial viability of our entire organization. Doing good for these children now jeopardized the good we did for many other people. I came to the conclusion that we needed to downsize these services very quickly.

Why not discontinue them completely? There were several reasons. The first and foremost was that they were a "feeder" for another service that we were developing for children with the most severe and complex challenges. At the time I made this decision, we had six operational private special education schools, and we were starting up another three. These schools promised to be even more effective in helping special children attain a better life, and they could be operated without incurring significant financial losses. By expanding these schools as we contracted our other children's services, we could continue to serve this very needy population in a financially responsible manner. To do so effectively, we needed to maintain a presence in the other children's services since they gave us credibility with this population and "fed" the schools many referrals.

Did I do good by continuing to provide services to children with serious and complex challenges while incurring millions of dollars of losses? Of course. Was the decision to continue these services a correct decision? Yes and no. It was correct initially, but in retrospect I should have reversed it earlier as our financial losses accelerated. Am I sorry for not reversing my decision earlier? No! I should have reversed it earlier, but I reversed it in time to avoid any serious damage to our other services and in a way that our commitment to serving this special population can continue and accelerate. In retrospect, I set the limit late but in time. Under the circumstances, that may have been the best decision.