Correctional Medical Authority

Meeting Minutes

CMA BUDGET AND PERSONNEL COMMITTEE

M I N U T E S

July 24, 1997

LOCATION: The CMA Budget and Personnel Committee met July 24, 1997, in the CMA Conference Room in Tallahassee, FL. Notice of the meeting had been published.

CALL TO ORDER: Tom Prevost, acting for the Chair, called the meeting to order at 10:05 a.m.

COMMITTEE MEMBERS IN ATTENDANCE: Russell Arent, Jeannie Baker, Mike Harris, Melissa Jacoby, James Kersey, and Tom Prevost

COMMITTEE MEMBERS ABSENT: James Bracher

CMA STAFF ATTENDANCE: Anne Allinder, Linda Keen, Martha King, Peggy Stevens and Mike Traugott

OTHER ATTENDEES: John Burke and Richard Prudom, Office of Health Services, DC

INTRODUCTION OF NEW MEMBER: Mike Harris was welcomed as a new committee member.

MINUTES: Minutes of the January 23, 1997, committee meeting were approved without objection.

OLD BUSINESS - REVIEW OF ACTION ITEMS: 1) OHS-Washington/Taylor CIs-Comparison (continued item) - Item will be covered during the OHS presentation. 2) OHS and B&P’s representative (Prevost) meet with ACHA representative (Cuddeback) on ACHA report card - Mr. Prevost informed the committee that Shands had changed CEOs and Cuddeback has to reevaluate his role, but still wants to work on the project. A meeting is scheduled for August 4, 1997, and this project is one of the discussion items. 3) OHS-Quantify savings in LBR - Ms. Stevens reminded the committee this was a recommendation made during the FY 1997-98 budget cycle, and the recommendation would be pertinent during the upcoming budget cycle. Mr. Burke responded OHS would not be quantifying savings in the FY 1998-99 LBR. He indicated that over the last three years whenever the department has quantified savings, the Legislature took those savings as cuts, and the department does not feel there is anything to be gained by documenting cost avoidance in the LBR. 4) OHS-Provide information on alternatives on how to deal with health care provider interaction in borderline medical encounters - Mr. Burke described briefly medical’s role in issuing passes and writing scripts. He indicated there are only two ways to approve passes, either security does it or medical does it. Security does not want the responsibility of issuing passes for legal reasons. The OHS will continue to look at the issue in terms of containing costs, but there is not much support in the department to move any marginally medical related things out of medical.

At this time Melissa Jacoby, joined the meeting.

REVIEW OF 1996/97 EXPENDITURE DATA: Mr. Prevost noted that the January 1997 financial data showed a $7.1 million surplus. Mr. Prudom provided the most current financial statement reflecting 11 months of data that showed a $1 million surplus. Mr. Burke indicated that the 12-month data reflects a $3.3 million surplus, after adjustment for reduction of new beds. He stated about $16 million was eliminated from the OHS budget over the course of the year. In July 1996, the department was anticipating increased population. Since that did not happen, the $16 million reduction was taken. The $7 million surplus in January was attributable to new bed money. Mr. Burke referred the committee to Attachment A of the package provided by OHS which reflected a four-year comparison of OHS expenditures. He noted that the FY 1996-97 population was less than the prior year, but that medical grades III and IV had increased. He pointed out the increases in drugs indicating they were affected by the use of protease inhibitors, which were begun in the previous year along with viral load testing. A factor not clearly reflected on the document is the effect of the mental health case load on drugs. He reported OHS is averaging $80,000/month for protease inhibitors and $240,000/month for psychotropic medications. Mr. Prevost noted that in the community hospital cost area the reduction in use rate is slowing, but the average length of stay is increasing slightly. Mr. Burke attributed the increased LOS to the chronic conditions of inmates staying in the system longer due to sentencing structure. Ambulatory surgery rates have increased. Increased use of the new mobile surgery unit at NFRC will help reduce the number of ambulatory surgeries conducted elsewhere. The committee postulated the increased ambulatory surgery rates could result in reduced inpatient surgeries. Cost avoidance issues taking place at NFRC including the mobile surgery unit, use of the old OR for scope procedures, radiation therapy and the chemotherapy unit were briefly reviewed. Ms. Stevens indicated the summary of cost avoidance information included in the packet was extremely helpful, and asked that the OHS continue to provide a summary of this type at each B&P meeting. Mr. Burke indicated it would not be a problem to do so.

Mr. Burke then proceeded to call the committee’s attention to the document mentioned by Ms. Stevens outlining the department’s cost containment initiatives. He identified the consolidation issue, specifically pharmacy consolidation. He noted that OHS was conducting a complete evaluation of the pharmacy consolidation, but that it was not completed. He referred the committee to Attachment A5 relative to staffing, and pointed out pharmacy staffing had been reduced by 12 pharmacist positions while only adding two health support workers due to the clustering of pharmacies. He also noted a reduction in inventory, increased control and less waste and "shrinkage." He noted that upon completion the pharmacy evaluation would be shared with the committee.

He then referred the committee to Attachment A6 pertaining to dental consolidation. He indicated salary cost avoidance due to dental consolidation approximated $2.5 million/year. He noted the ratio of dentist to inmates had increased from 1:600 to 1:772, per diem had dropped $.11, and production had increased slightly. He noted that the OHS was also in process of evaluating the dental consolidation. Ms. Keen pointed out that CMA surveys have minimal problems with delivery of services in the pharmacy clustering, but that surveyors were beginning find problems with delivery of services related to dental care. She explained that surveyors were reporting significant delays in dental care, although it was not evident at all institutions surveyed. She indicated she would keep the committee advised of future findings. Mr. Burke and Ms. Keen discussed the issues involving minimum standards of dental care.

Ms. Stevens then directed the committee to the demographic and workload trend data. Mr. Burke specifically pointed out the increased in psych grade IIIs over the course of the fiscal year. Ms. Stevens pointed out several categories showing reductions in the rate of use of services. She also noted that while the prevalence rate for inmates known to have HIV disease was relatively stable, the prevalence rate for inmates with AIDS had increased from .9% in FY 92/93 to 1.2% in FY 96/97, a 33% increase. Mr. Burke attributed some of the increase to longer sentences; inmates are not cycling through the system as they did in the late 80’s. Inmates who enter the system with AIDS, will now likely die within the system. Inmates who enter HIV positive will likely convert to AIDS at some point during their sentence.

REVIEW OF 1997/98 LEGISLATIVE APPROPRIATIONS: Ms. Stevens directed the committee’s attention to spreadsheets comparing the 97/98 LBR and legislative appropriations. She also noted that the CMA’s funding was zeroed out due to the transfer to the Department of Health. Mr. Prevost noted the FY 96/97 budget was about $220 million prior to the $16 reduction related to beds, and the FY 97/98 funding is $216 million. Mr. Burke clarified that including certified forwards, the OHS spent about $2.4 of $2.7 million available. He indicated the 98/99 appropriations act reduced positions, accelerates consolidation, and requires a plan be submitted to the Legislature by January on how that will be accomplished. He noted that appropriations for the expense and AIDS categories were less than the prior year’s actual expenditures. He also noted that of the $216 million appropriated, at this time the OHS has been allocated $206 by the department’s budget office. He anticipates a deficit closing FY 97/98. Ms. Keen noted that this year’s appropriations language carries proviso that the 126 FTE and $3.9 million necessary to fund enhanced security at close management institutions is to be generated from health services consolidation efforts. She also noted that the CMA had concerns about the dental HSB when it was revised in the previous year and had it reviewed by an outside provider. There were a number of areas where it was felt the care outlined in the HSB was below community standard and the CMA had a number of comments about the OHS’ dental plan. She expressed the concern it was likely that in the future the CMA would be commenting the care provided within the confines of the money appropriated does not meet community standard.

There was discussion about the potential for deficits resulting from the budget appropriated. Mr. Prevost encouraged the committee to monitor the budget and if it becomes obvious over the course of the fiscal year budget deficits are impacting the quality of care, the committee needs to report that information. Ms. Stevens noted that the projected average daily status population for FY 97/98 according to Economic and Demographic Research is in excess of 67,000. Mr. Burke noted this is an increase of about 5,000 inmates, a substantial impact.

PRESENTATION ON STATUS OF THE OFFICE OF HEALTH SERVICES:

A. Washington/Taylor CIs - Mr. Burke commented the comparison of Washington and Taylor CIs had been terminated. The institutions are no longer sister institutions due to the assignment of psych grade IIIs to Washington. Also, the department, privatization commission and the private vendors could not come to agreement on each other’s costs. Mr. Burke reported that the Auditor General in currently involved in conducting new studies to determine how to equalize the costs of public vs. private facilities. Responding to questions from Ms. Jacoby, Mr. Burke indicated that the AG was determining total costs, not just health care, and the response is to be available prior to the beginning of the next Legislative session.

B. Comparative Cost Analysis Date - Mr. Burke indicated that due to staff and time constraints the OHS had not updated the data, but that the OHS was moving in that direction. He indicated he was hopeful there would be additional data available by the next meeting date. He indicated the OHS is working on reviewing data on an institutional basis for comparative purposes. Comparisons of average daily population (ADP) for medical grades, psych grades and the various major categories of services, i.e. medical, dental, mental health, pharmacy, etc. are being analyzed.

Responding to a question from Ms. Baker, Mr. Burke explained how inmates are assigned to institutions. Mr. Burke indicated while medical attempts to work with classification to place medically impaired inmates at institutions where it is most favorable for OHS in containing costs, they are not always able to do so. He also noted the department had just opened two medical dorms at NFRC. One dorm will have 24-hr nursing staff; the other will house inmates who don’t need 24-hr nursing care, but need to have it closely accessible. He also indicated the OHS had received approval from the institutional mission committee to move all the AIDS cases from 60 institutions to 26, and the medical grades III and IV to a smaller number of institutions. The staffing plan is being finalized for presentation to the Executive Leadership Board in August.

C. Performance Based Budgeting (PB2) - Ms. Stevens directed the committee to materials in their packet which they might wish to review during Mssrs. Burke and Prudom’s presentation. Included in the materials was the CMA’s response to a request by the DC Inspector General for input on the OHS performance measures, and possible performance measures that would incorporate results of CMA surveys. Mr. Burke indicated proposed performance measures were submitted in November 1996. Responding to a question from Ms. Jacoby, Mr. Burke indicated the OHS FY 98/99 budget would be based on PB2 measures. Mr. Burke summarized the OHS’ participation in the PB2 process up to the current date. Mr. Burke indicated his understanding of PB2 will result in an impact-based budget, rather than a pure performance-based budget. In other words, the budget will be based on those issues which the public feels have an impact on how their dollars are spent. A set of performance measures approved July 3 was distributed. Ms. Keen indicated she had attended the meeting of the department, legislative and governor’s staff. She noted her understanding of the meeting was the DC would incorporate at least one performance measure relating to CMA surveys. Mr. Prudom responded that DC administration had indicated at this time the performance measures would not be modified. A discussion relative to the philosophy of performance based budgeting and how it could be used as a tool to explain shortfall situations ensued. Ms. Jacoby commented on the necessity of having clear outcomes.

The committee recessed for a break.

NEW BUSINESS/MISCELLANEOUS:

A. Presentation On Summary Of Site Visit To Texas - Ms. Stevens indicated that she and Mike Traugott made a site visit to Texas in June to review its managed care and telemedicine operations. She indicated the presentation on managed care would be presented at the current meeting, and the presentation on telemedicine would be presented at the meeting in October. She indicated they had the opportunity to meet with a variety of people in Texas. They included:

Jim Riley, Executive Director for the Correctional Managed Health Care Advisory Committee

Leon Clements, the Associate Vice-President for Managed Care at the University of Texas Medical Branch, and his staff;

Jason Calhoun, the Medical Director at UTMB and members of his staff;

Mike Warren, the Medical Director for the Texas Department of Criminal Justice Health Services division;

Bill Gonzalez, the Medical Director for Managed Care at the Texas Tech University Health Science Center and members of his staff; and

Bea Moorhead, of the staff of the Texas Comptroller.

She reported she and Mike had the opportunity to tour the TDCJ hospital at Galveston, observed Telemedicine clinics in operation, and attended the weekly utilization review meeting. At Texas Tech they observed Telemedicine clinics and toured the Montford psychiatric/medical unit. Ms. Steven’s presentation is included as an addendum to the minutes.

At the close of her presentation, Ms. Stevens distributed information on the biennial budget just passed in June by the Texas Legislature. She noted that the Texas fiscal year runs from September 1 to August 31.

Discussion resulting from the presentation is reported below:

Mr. Burke expressed several concerns about comparing the Texas system and the Florida system. He indicated that OHS had received a number of contacts from the Texas legislature about the process. He indicated the Texas legislature has commissioned an evaluation of the program. Mr. Burke indicated that while the media reports are good, people who call him are saying they are getting some questionable results. Transportation costs are one of the criticisms of the system. He also shared that department staff who have participated in NCCHC accreditation surveys in Texas have indicated that in 1993-94 TDCJ assumed responsibility for a number of jails and short-term prisons and the time frame for scheduling routine specialty consultations is six months. He also stated that in Texas an inmate is eligible for release upon completion of a drug treatment program. He noted that surveys indicated that inmates who needed a consultation were transferred to a standard institution and removed from the drug treatment program. He linked this to an allegedly high rate of refusals. He also reported that although both universities were supposed to have a quality management program, they had not implemented one. He indicated that according to Texas legislative staff, this was one of the criticisms by the people doing the study. He indicated there were also questions about the accuracy of the utilization data. Mr. Burke stated that when OPPAGA conducted its recent study of health services, they visited Texas, but did not find many direct comparisons. Mr. Burke indicated the study should be completed by October. Mr. Burke reported Texas legislative staff indicated to him they thought it would be a glowing evaluation and it’s not. He reported the first draft of the report has been reviewed. He indicated a number of people from Florida participate in NCCHC evaluations and the firm that is conducting the evaluation is from Florida.

Ms. Stevens encouraged the committee not to focus on per diem rates of the two programs, but on the possibility of a link between the public university medical schools and the prison system.

Mr. Prevost stated his belief that everyone wants quality care at the best cost. And, although Florida is pleased with the track it has taken in providing health care, it can’t be complacent about that track; that we can always learn from others. He indicated he believed we need better information on the comparisons.

Ms. Keen expressed interested in a further explanation of what Texas’ managed health care concepts are and how they implement them.

Mr. Burke also brought up the Georgia experience relative to privatization of health care, and how it was unsuccessful. He indicated that Georgia’s response was to move to a system linking the University of Georgia and the prison system with little study. He expressed the concern if Florida surfaces another way of providing health care, we’d better be prepared to lose what we have, and better hope what we’re going to has the capability of doing the job. He indicated what he is hearing about the Texas system reminds him of what he heard several years ago about the California system. California received a number of awards regarding their system. He indicated those awards were apparently based on ideas as opposed to implementation of programs, and California is back in federal court. He indicated Texas has made a concentrated effort at avoiding providing comprehensive data, and it was hard to find out exactly what they are doing. He reported that less than six months ago, Texas contacted OHS and wanted all the information on OHS’ utilization management program and the HSBs, and subsequently have requested all the HSBs. He again referenced the independent Texas evaluation, and indicated it may provide the information for use as a starting point. He expressed his concern that anything touted to the legislature relative to saving correctional dollars is implemented, whether it’s a good idea or not.

The committee agreed to have continued discussion relative to the Texas managed care model and its link with the public universities at the next meeting. The emphasis is on exploring what, if any, portions might be useful in Florida.

B. Next Meeting Date - October 23, 1997

Mr. Burke indicated it was the week the special care unit was opening in Orlando. There was discussion about possible conflicts with legislative committee week. The meeting date was later confirmed by phone call to all members.

ADJOURN: The meeting adjourned at 1:10 p.m.

Respectfully submitted,

Margaret A. Stevens

Senior Management Analyst