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HomeMy WebLinkAboutMINUTES - 04082008 - D.4 TO: BOARD OF SUPERVISORS Contra mss• FROM: Health Services Department 10, n ,Y �r'z Costa William Walker, M.D., Director � o�` � '� County sr'9 COUNT DATE:: April 8, 2008 SUBJECT: Health Services Workshop on the Future of Health Care Delivery SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: 1. RECOGNIZE that given the 24/7 nature of hospital and detention medical services and the regulatory environment, significant budget reductions are not feasible. 2. RECOGNIZE that our current model of health care service delivery through out hospital and clinic system requires constantly increasing levels of General Fund subsidy. 3. RECOGNIZE that the County's ability to raise significant resources to maintain our current health care model demands consideration of alternative models for meeting our health care obligations. 4. RECOGNIZE that changes to the Basic Health Care Program are unlikely to provide current year budget relief. 5. AUTHORIZE the Health Services Department to proceed with the Public/Private budget balancing options. 6. REVIEW the pros and cons of alternative governance structures for the Hospital and develop a process to examine cost impacts, service impacts, and other potential service and cost containment options. � W� �1� CONTINUED ON ATTACHMENT: X YES SIGNATURE: , RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): ACTION OF BOA D N '�^ / 1,�,Q o`�J Q APPROVED AS RECOMMENDED OTHER R? VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON MINUTES OF f THE BOARD OF SUPERVISORS ON THE DATE SHOWN. UNANIMOUS(ABSENT I ON ) AYES: _ NOES: ABSENT: ABSTAIN: Contact: Dorothy ity soeSer icesD ep cc: Community Services Department ATTESTED County Administration JOHN ULLEN,CLERK OP THE BOARD OFSUPERVISORS BY: c ( DEPUTY Page 2 of 6 FISCAL IMPACT: No irnpact from this update. However, based on the direction provided by the Board of Supervisors to the Health Services Department, significant fiscal impacts may occur at a later date. BACKGROUND: The Board of Supervisors is acutely aware of the 2008/09 budget outlook. In anticipation of the upcoming budged hearings information has been requested concerning the impact on the medical delivery system operated by the Health Services Department. This report is not meant to replace the budget hearings, nor is it intended to minimize the impact of budget reductions to other areas of the Health Services Department budget such as Mental Health or Public Health. This report is intended to highlight the significant difficulties in reducing expenditures in the twenty-four hour, seven-day-a-week, medical facilities. Hospital/Detention Introduction: In contemplating reductions in the medical care provided by the Contra Costa Regional Medical Center or in the medical and psychiatric services provided to inmates incarcerated in the Jail, special consideration must be given to the regulatory and quality of care environment in which the health care profession operates. General Healthcare Environment: • The demand for County provided medical care services are at an all time high. • The County does not have the financial wherewithal to invest more and more general fund to maintain minimal service levels. • The average number of monthly births at CCRMC in 2005/06 was 178. Current year monthly births are averaging 212 -an increase of 19%. • Emergency room visits in 2005/06 averaged 3,391 per month. The current year average is 4,013 - an increase of 116%. • The time to get a Specialty appointment in the clinic system now ranges from a 100-day wait for Urology, to 60 days in ENT, to 50 days in Orthopedics. • In 2005 same day Family Medicine appointments were fully utilized by 10:00 a.m. In 2006 they were fully utilized by 8:30 a.m. Currently they are fully utilized by 7:30 a.m. • National reform to address the issue of the uninsured has not occurred. • Statewide reform to address the issue of the uninsured has not occurred. • The lack of a National or Statewide approach for the delivery of health care services to the uninsured places the County, by default, as the "provider of last resort." Page,3 of 6 Balancing Options at the Macro level: Generally, the only way to impact the overall cost of health care is to: (a) Reduce the unit cost of Medical Care Services, (b) Reduce the number of people covered by the County, or (c) USE: a combination of(a) and (b) above. Hospital/Detention 24/7 Regulatory Staffing Requirements: • As a reference point, the vast majority of the Hospital/Detention budget is utilized to staff the facilities. Seventy-two percent(72%) of the budget is devoted to Salary and Benefits. The balance of the budget is directed to normal operating expenses such as pharmaceuticals, blood products, dietary, etc. • Title 22 of the Health and Safety Code mandates Nurse-to-Patient Staffing Ratios in the hospital. • State and f=ederal licensing and accreditation regulations mandate the standards a hospital must adhere to. The regulations by their nature effectively dictate staffing levels to insure that appropriate medical care is delivered. • On September 27, 2006 the hospital had a CMS validation survey. As a result of this survey, the hospital was cited by CMS (December 18, 2006)for being out of compliance with Medicare Conditions of Participation. An aggressive plan of correction was submitted on January 8, 2007. Work focused on improving quality of care delivery across disciplines including patient safety, documentation, quality improvement projects, and engaging the governing body. A re-survey was conducted on January 9, 2008. • The issues raised by CMS were primarily the result of repetitive budget reductions and the inability to adequately maintain a comprehensive quality management and safety system in the hospital.timli • The citations, if not corrected, would have resulted in a loss of over $200,000,000 in federal Medicare and Medi-Cal revenues. • Over the last 14 months the hospital, at the Board's direction, undertook at considerable expense a total re- work of the quality management and safety programs. New psychiatric physicians were hired for inpatient psychiatry and for the Crisis Stabilization Unit. Staff(medical and nursing) underwent extensive training in safety issues. A new Safety and Performance Improvement Department was created in the hospital. New systems of quality review and management were put into place with the help of outside consultants. • January 24, 2008 CMS issue a formal finding of compliance. All issues were resolved. • Reductions to current staffing levels will jeopardize all the efforts recently completed to address the regulatory concerns and would again put at risk over$200,000,000 in federal and state revenues. Basic Health Care Program: • The Basic Health Care (BHC) program provides a structure for the provision of legally required medical care services to indigents of the County. The program attempts to link the individual to a medical home and utilize managed care principles to lower the overall cost of care. The individual is generally enrolled at the point of service, i.e., when medical care is needed. • The average monthly program enrollment is 5,000 individuals. 1 Page.4 of 6 • The annual cost for this program is approximately $40,000,000. • Individuals are eligible for the program if they are at or below 300% of the Federal Poverty Level and have assets of less then $4,000. • A sliding fee scale ranging from $0 to $75 per month is in place. • The current monthly Federal Poverty Level (FPL)for an individual is: • 1000X)= $ 851 • 1250/x= $1,064 • 2000%= $1,702 • 3000/c,= $2,553 • Seventy-Nio percent(72%) of the individuals enrolled in the program are at or below 125% of the Poverty Level. • Nineteen percent(19%)of the individuals enrolled in the program are between 126% and 200% of the Poverty Level. • Nine percent(9%)of the individuals enrolled in the program are between 201% and 300% of the Poverty Level. • The County is legally required to base its eligibility standard for indigent health care on its residents' ability to pay for subsistence medical care. In order to determine the "ability to pay," a study to determine the cost of living in the County will need to be conducted. The study outcome is unknown. But even If the study indicates that the 300% of Federal Poverty level can be reduced it may not have a significant impact on the demand for County services. As long as the County runs a hospital with an emergency room, it will be legally required to provide services when patients arrive on the campus. The threat to receive a bill from the hospital may delay and possibly prevent some patient treatment requests - but how many is speculative. Conclusion: • Reducing the cost of Health care services by $10 million is improbable given the mandatory staffing requirements and the County employee pay and relatively high employee benefit structure. • Reducing the number of individuals covered by the County's indigent care program will be difficult and may not result in significant savings. Other Budget Options: • Public/Private Partnership: To maintain existing services and meet the budgetary constraints of the current budget, an alternative approach could be considered. The approach would utilize private sector firms to perform certain functions within the County. This approach would require a multi-year implementation process with portions of savings occurring in the current budget year with growing savings in the out years. o Process: Issue a formal Request for Proposals for the provision of services in the following areas (non inclusive): 1 Page 5 of 6 (a) Detention Health Services (b) Inpatient Psychiatric Services (c) Security Services (d) Medical Records Coding ('e) Housekeeping Services (f) Landscaping Services (g) Facility Maintenance (h) Laboratory Services (i) Collection Services o Priority for Bid and Implementation: To generate the largest amount of savings and to validate the potential savings associated with the use of private sector firms the first two areas to consider are as follows: (A) DETENTION MEDICAL: Provides all primary care medical services for inmates in the County's detention facilities, including diagnostic testing, treatment, nursing care, obstetrical, dental and other services. Provides assistance to the Sheriffs Department in the identification and management of the mentally ill in the County's Main Detention Facility. Services include medication management, behavior man- aclement, crisis counseling, and brief therapy. A number of Counties utilize private firms for the provision of this care (e.g., Alameda). Potential budget year savings: $2,000,000 to $3,000,000. (B) INPATIENT PSYCHIATRIC: An option is to develop a new multi-program psychiatric campus. Background: Up until this last year, the County has had two psychiatric programs within the walls of its County hospital: a 43-bed acute psychiatric inpatient unit and a psychiatric emergency service, which provided 24/7 crisis services. Approximately one year ago, the Hospital closed 20 of its 43 acute inpatient psychiatric beds and converted the psychiatric emergency service to a crisis stabilization unit of the Emergency Department. Opotion: (1) Purchase property(sites have been reviewed and are available). (2) Build (a) a 16-bed psychiatric health facility (PHF)which would be for County residents being brought in involuntarily, (b) a 16-bed crisis residential program, which would be for individuals who have converted to voluntary status but who still need a 24/7 structured treatment program, and (c)a new Assessment and Recovery Center, which will provide services to both individuals being brought in involuntarily and individuals who voluntarily seek mental health services. The Center will be set up to accommodate both levels of care by having separate entrances and egress, and separate program space for each. These three new programs will provide for a continuum of the most acute psychiatric care possible, and will allow an individual to transition from one level of care to the next as needed. (3) Utilize a Community Based Organization to run the program (same model as the Oakgrove facility; the County owns the property and a CBO runs the program). (4) Close the CCRMC inpatient unit. Page,6 of 6 (5) This will take eighteen to twenty-four month lead-time to accomplish. (6) Potential savings of$1,000,000 annually can be achieved. Budget Option Summarv: Utilizing the Public/Private option could potentially save $3-$4 million in the budget year. Budgetary savings in the out years could range from $6-$9 million annually. Future Planning: The health care environment is significantly different from a century ago when Contra Costa County began providing hospital care to the indigent. The health care marketplace is now more influential than ever before; regulations are much more stringent, medical care providers must now adapt to the rapid pace of change in technology and the labor market, as well as the ever-changing needs of the patient. The ability of the County to continue to deliver health care to its residents may rest on a change to the governance structure of the Health Department. A structural change that would realign functions such as Physicians, Contracting, Purchasing and Human Resources under the Health Agency reporting to a stand- alone Board may provide the vehicle to slow the ever-increasing rise in medical costs. Alternative Public Governance structures exist. They range from Health Commissions (San Francisco), Stand alone Authority (Alameda), to our own local Joint Powers Authority (Doctors Hospital). The Health Services Department will continue to provide the Board of Supervisors, the community and staff with regular updates and educational sessions and materials as research develops. ADDENDUM TO ITEM DA April 8, 2008 On this day, the Board of Supervisors considered accepting report and recommendations from the Health Services Director regarding alternative governance structures for the delivery of hospital services. Dr. Walker presented an update on the impacts of the medical delivery system operated by the Health Services Department. He highlighted the significant difficulties in reducing expenditures in the County's 24 hours/day, 7 days/week, medical facilities. He went on to say the only way to impact the overall cost of health care would be to reduce the unit cost of medical care services, reduce number of people covered by the County, or a combination of both. He explained that the majority of the Hospital/Detention budget is utilized to staff the facilities. He said reductions to staffing levels would jeopardize efforts recently completed to address regulatory concerns and would put at risk$200 million of federal and state revenues. Dr. Walker stated the Basic Health Care Program has 5,000 individuals enrolled with an annual cost of approximately$40 million. He pointed out that reducing health care services by$10 million would be improbable and to reduce the number of individuals covered by the County's indigent care program would be difficult. In conclusion, Dr. Walker suggested that a way to meet current budget constraints would be to utilize private sector firms to perform certain functions within the County. He pointed out the County should issue a formal Request for Proposals for the provision of services in Detention Health services; Inpatient Psychiatric services; Security services; Medical Records Coding; Housekeeping services; Landscaping services; Facility Maintenance; Laboratory services and Collection services. He pointed out to generate the largest savings would be to consider Detention Medical and Inpatient Psychiatric services. Dr. Walker strongly emphasized that utilizing the public/private options would potentially save $3-$4 million and that a budget savings in the future years could range from $6-$9 million annually. Supervisor Piepho noted that considering the circumstances at the federal and state level, the County does not have many options and said reducing staffing means the County would need to reduce services. Supervisor Gioia requested Dr. Walker to summarize a March 7, 2008 memo (attached) to the Joint Conference Committee,which was also addressed to Chair Glover and Supervisor Gioia that compared costs among public and private hospitals in the area. Dr. Walker noted that the memo compared information concerning the hospital's employee benefit package relative to other areas. Supervisor Gioia said the County' Health Department's leadership and hardworking staff at all levels should be proud of the quality of this County's health care system and said the County's collective goal should be to maintain and to keep it strong. He noted his goal would be to work with the larger community to allow the County Health System to 1 be sustainable over time. He noted that hospitals and clinics are different from other programs in what can be cut and still maintain quality care. Supervisor Bonilla asked Dr. Walker how many counties in the state of California have public hospitals. She recognized that there would be service impacts and acknowledged that the County is examining the benefits portion of compensation for each employee. She said it is premature to discuss comparing the Contra Costa Regional Medical Center (CCRMC)with an 81.7% employee benefit load with other area hospitals when we are simultaneously discussing reducing that number. Dr. Walker responded there are about 19 public hospitals in California and that the demand for County-provided medical care services is at an all-time high. He cited only one public hospital closure in the last decade. He said that the department regularly tries to balance its needs with what the community needs. There are some areas in which the County is the only health care option in the area and we cannot reduce those areas. But there are some areas where we know we cannot send our patients elsewhere. There are areas in which we propose to do something different without adversely impacting service capacity. Supervisor Gioia noted the importance to recognize that this issue exists with or without Other Post-Employment Benefits (OPEB). He said that the numbers referenced in the memo (attached) do not include OPEB and said the County is high without the OPEB issue and needs to consider the proposal irrespective of OPEB. He amplified Dr. Walker's comments and said that once Doctor's Medical Center Obstetrics closed, one- third of births in the County now occur in CCRMC. He said we cannot afford to close the County Hospital but if we continue on our current course, the County will not be able to afford to keep the hospital open. Supervisor Uilkema asked Dr. Walker if he has taken into consideration potential impacts from the State budget on this system, as currently described by him. Dr. Walker responded that the Health Services Department has not anticipated things that have not as yet been approved. Chair Glover asked the public for its opinions and suggestions, and several people offered their comments. The following people spoke regarding the proposed options to utilize private sector firms to perform certain functions mentioned in the said Board Order; • Doran Lamb, Engineering Services Department, CCRMC; • Charles Holley, Baypoint resident; • Fred Morse, Martinez resident, handed the Board literature on SODEXHO; • Paul Adams, Antioch resident; • Paula Banks, Pittsburg resident; 2 • Sunny Boyer, Martinez resident; • Roland Katz, Business Agent, Local 1, handed the Board literature on several documents about contracting out health care; • Elio Bracho, Berkeley resident: • David Ezra, Berkeley resident: • Roberta Kayser-Stange, Pacheco resident: • Vincent Aguigui, Jr. Martinez resident; • Ralph Hoffman, Walnut Creek resident; • Lloyd Cline, Martinez resident; • Kathleen McLaughlin, Martinez resident, said the County should explore options by Dr. Walker; • Christopher E. Dodd, suggested fundraisers to meet budget needs; • Tanir Ami, President the Contra Costa Contractors Alliance/Community Clinic Consortium, encouraged the Board to look at how best it could provide services to the underserved, and requested the Board to look at the partners they have; • Martha Wilson, Psychologist, Mental Health, suggested the County examine the jail population to expand community clinics, and noted that the jails cost the County a lot of money. She also asked the Board to consider Health Services Department and Mental Health Services Department to work together, and • Marshariki Kurudisha, GRIP, informed the Board she supports the previous speaker's comments. She suggested the Board discuss with cities what can be done with mental health care. She requested the Board examine the empty facilities in West County already built to develop new partnerships. Supervisor Gioia observed that this issue has been framed as an"either/or" issue, but it's really an issue of degree or level of benefits, not whether the County provides benefits or not. He maintained that OPEB is not merely an accounting issue but a real fiscal liability. He explained the County's personnel benefits are higher than competitive private and public hospitals and that has caused some of the imbalance in the County Budget. He asked everyone to think about the thousands of Contra Costa residents who would have their health care reduced or eliminated in order to support higher than average benefits for employees. He observed that many of the people the County serves do not even have health care benefits. He said the growth in health care 3 and retirement costs has put the County at a higher cost level than other facilities and said he agrees with those who requested more data. He concurred that surveys should be conducted to include benefit costs and not just the compensation (wage) costs. He stressed that eliminating all management positions would not solve the problem. Supervisor Gioia noted the County should strive to achieve efficiencies at all levels and remarked the benefits for management should be cut back too. In addition, he stated the Board would look at cutting back its own benefits and those of other non- represented staff. He pointed out that his goal is "how do we maximize our service level to the community while maintaining fair and competitive compensation." He opined that the challenge could be achieved by working together. He went on to say some of the alternatives presented by Dr. Walker should be examined and said the County should move ahead looking at the issue of Detention Medical and the issue of the psychiatric restructuring. He indicated that these two proposals merit further study. He added that where there is a need to "meet and confer", it would be done. He elaborated the alternatives would be to reduce costs in areas such as Detention Medical and Psychiatric or else more layoffs would be required. Supervisor Piepho agreed with Supervisor Gioia's remarks and referred to Dr. Walker's presentation, indicating those are often the Solomon-like decisions with which the County is faced. She added that the County would need to study the entire situation to gain information accurately and effectively to make good,balanced, and thoughtful decisions. She observed that the direction before the Board is to recognize the problems, review the pros and cons of alternative governance structures for CCRMC, and develop a process to examine service impacts and other potential service and cost containment options. She opined that these actions are prudent for a county like Contra Costa that is faced with severe financial constraints from the retiree health care liability to the current budget crisis. She added that the Board is committed to make balanced, thoughtful decisions to be effective in its role of governance. Chair Glover acknowledged that the options brought before the Board are extremely difficult and the impacts are significant, but he appreciated the opportunity to try and find a balance within those options. He observed these impacts affect the State of California and the nation, and added the Board will try to find an intelligent solution that balances employee needs with the need to maintain health care service levels. In conclusion, he concurred with Mr. Katz in terms of his analogy that the County cannot solve the national health care crisis, but reiterated the County is faced with this problem at a local level,which needs to be addressed. Supervisor Uilkema referred to the Board Order and stated she would like more information on items"c"through"i" (see Board Order D.4 dated April 8, 2008 page 5). She referred to the last page, third paragraph under"future planning" and asked what the options are, and said the Board should have other possibilities to review. Still referring to the same paragraph, Supervisor Uilkema questioned how the public hospital could become a"stand alone" authority and asked for a general description to see if the County would pursue this issue. 4 Supervisor Bonilla observed that Recommendation No. 5 is broad and recommends proceeding with a larger list of contracts than those specifically listed. She suggested a wording change under Recommendation No. 5 to read: AUTHORIZE the Health Services Department to proceed with researching Public/Private budget balancing options for Detention/Health and Inpatient Psychiatric (only). She emphasized she is not in favor of proceeding with this recommendation as a budget balancing option. She disagreed slightly with Supervisor Gioia regarding his statement that this is about OPEB, and pointed out in OPEB current health benefits are discussed for active employees and not only retirees. She remarked that the Board is not being given a chance to negotiate or implement what that would mean with these numbers about an 80%benefit load. She asked what the benefit percentage would be if, at certain levels, the County could renegotiate health benefits. She indicated that using the 80% figure is not a valid benefit load because it presumes that the County achieves no cost containment changes. County Administrator John Cullen said the benefit load indicated on that memo does not include the OPEB liability, and that the memo reflects employee benefits for fiscal year 2005/06. Supervisor Bonilla responded it also does not include any renegotiated health benefits. She said the memo is out of context and should it have been brought forward a year ago it would have been in context. She said the Board is being asked to take a course of action without the information of what the cost savings might be. She recalled her earlier concerns about it not being feasible to achieve all of the necessary cost reductions in one year. Supervisor Bonilla addressed Mr. Cullen and said some things have not been achievable. She said the Board is potentially establishing a precedent for the entire organization and that she does not want to set that precedent as a solution. She said that, at some point, there needs to be a discussion to consider whether or not the Board set cost cutting goals that were too ambitious. Supervisor Gioia recalled that property tax and other revenue growth have slowed because of the stalled real estate market. He clarified that no one has discussed in this budget negotiation taking away any existing health benefits. He said freezing or lowering health care cost growth significantly decreases OPEB liability, and observed that the only way to achieve that end is to ask employees to pay greater premiums for health care. He opined the County needs to determine the benefit structure for the County. If our health care benefits are significantly higher than competing health care systems,we need to address that. Supervisor Gioia suggested moving forward with the Health Services Director's recommendations, with the addition to issue a Request for Proposals for Detention/Medical and the Inpatient/Psychiatric option, as described in the Board Order. He augmented the recommendation including having a consultant initiate a total compensation survey for the hospital and health clinics. He amended 5 Recommendation No. 5 to read: AUTHORIZE the Health Services Department to proceed with researching public/private budget balancing options for Detention/Health and Inpatient Psychiatric; and DIRECT staff to secure a consultant to conduct a total compensation survey for the hospital and clinic system, which includes among others c through i (page 5 of 6) and other relevant operations for the hospitals and clinic; and incorporated Supervisor Uilkema's suggestion of continual analysis on the governance issue to include health agencies among other options. Supervisor Piepho pointed out that she would like to make sure the number of employees be included in each of those classifications for the survey. Chair Glover advised that before any of these actions take place it would be reported back to the Board and the Board would then move forward. Supervisor Gioia said the Board would work with labor on a number of these issues as other solutions are explored to make the health system viable. Supervisor Bonilla said that she would like a report on Inpatient Psychiatric from the Director of Mental Health, the Mental Health Commission, and other mental health professionals, and reinforced that she would not advance any proposal without consulting Mental Health professionals in the field and listening to their recommendations. She stressed this is not a budget issue but about the quality of our care and reiterated she would like to hear about this regarding the Detention Medical and Inpatient Psychiatric. Supervisor Bonilla referred to suggestions made by speakers and suggested taking those suggestions into consideration. She requested a cost analysis on one of the suggestions made on opening more clinics and whether or not doing so would be cheaper than an emergency room treatment. She reiterated she would not move further until she sees all information related to any of these issues. By an unanimous vote with all Supervisor present, the Board of Supervisors took the following actions: APPROVED Recommendation Nos. 1, 2, 3, 4, 5, and 6. • AMENDED Recommendation No. 5 to read: AUTHORIZE the Health Services Department to proceed with Public/Private budget balancing options (e.g., issuing an RFP) for Detention/Health and Inpatient Psychiatric services. INCLUDED the following additional recommendations: • DIRECTED that a consultant be recruited to conduct a survey of total compensation for the hospital and clinic system to include among others those jobs related to Security services, Medical Records Coding, Housekeeping services, Landscaping services, Facility maintenance, 6 Laboratory services, Collection services, and other relevant operations for the hospitals and clinic; • Before proceeding with(c)through(i), consider results of the compensation survey in any further discussions for public/private partnership; • DIRECTED the County Administrator's and Health Department staff to work with Supervisor Gioia to analyze alternative public governance structures; and • DIRECTED that the County Administrator and Health Services Director report back to the Board for further direction before any changes are implemented. 7 WILLIAM I3. WALKEI:, M. D. ' OFFICE OF THE HEALTH SERVICES DIRECTOR " DIRECTOR 50 Douglas Drive,Suite 310-A Martinez,California CONTRA COSTA94553 Ph(925)957-5405 _ HEALTH SERVICES Fax(925)957-5401 March 7,2008 Federal Glover, Supervisor District 5 John Gioia, Supervisor District 1 Chair, Contra Costa Board of Supervisors Contra Costa Board of Supervisors 315 E. Leland Road 11780 San Pablo Avenue#D Pittsburg CA 94565 El Cerrito CA 94530 Dear Supervisors Glover and Gioia: During the meeting of the Professional Affairs Committee of the Contra Costa Regional Medical Center of February 21,2008, you requested comparative information concerning the hospital's employee benefit package relative to other area hospitals. The following is an attempt to be responsive to that request. Summary: Employee Benefits as a percent of salary (excluding OPEB Liability) Fiscal Year Ending 2006: Contra Costa Regional Medical Center: 81.70% Alameda County Medical Center: 62.22% Santa Clara County Medical Center: 59.18% Doctors Hospital San Pablo: 44.20% John Muir-Walnut Creek Campus: 48.25% John Muir-Concord Campus: 47.22% All hospitals in California are required to annually report detailed financial and utilization data to the Office of Statewide Health Planning and Development(OSHPD). This report is based on a uniform reporting system (i.e., all hospital reports are prepared in a uniform manner,using OSHPD definitions). Hospitals are required to submit reports, within four months of the close of their accounting period. After receipt by OSHPD they are desk audited, and the corrected data are input into the OSHPD database. In addition, if individual hospitals wish to revise their data they may. Periodically (at least annually), data files are posted on the OSHPD website. The most recent file available on the website covers hospital accounting periods ending during 2006. According to the Accounting and Reporting Manual for California Hospitals, which governs the reporting system, employee benefits are defined as,"A pension provision,retirement allowance, �'=` �' x • Contra Costa Alcohol and Other Drugs Services • Contra Costa Emergency Medical Services• Contra Costa Environmental Health• Contra Costa Health Plan ""y' • Contra Costa Hazardous Materials Programs •Contra Costa Mental Health• Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers I Federal Glover, Supervisor District 5.,Chair John Gioia,Supervisor District 1 Contra Costa Board of Supervisors March 7,?003 Pale 2 insurance coverage,paid vacation, sick leave, and holiday time off or other cost representing a present or future return to an employee,which is neither deducted on a payroll nor paid for by the employee." The OSlIPD data should be viewed within the context of being self-reported and unaudited. There are no consequences for erroneously filed reports. Accordingly, we contacted Doctors Hospital, Santa Clara Valley Medical Center and Alameda Medical Center to validate and confirm the salary and benefit numbers contained on the attached schedule were accurate. All facilities, either corrected or validated the numbers contained on the schedule. The John Muir Concord and John Muir Walnut Creek data are taken directly from publicly filed OSHPD statements. The data are believed to be accurate but due to timing constraints independent validation did,not occur. Please note OSHPD data does not provide Salary and Benefit information at the detailed employee classification level, e.g.Nursing. Please advise if additional information or clarification is required. Sincerely, n Patrick Godley Chief Operating Officer/Chief Financial Officer Contra Costa Health Services cc: William Walker, M.D., CCHS Director and Health Officer Jeff Smith, M.D., CCRMC and Health Centers Executive Director John Cullen, County Administrator Lisa Driscoll. County Finance Director Linda Ashcraft, County Labor Relations Manager �o �o a� a; �m a o o moo o U m m mVI M M m O n C� CT o � N U g O T a m ON O •�W• Vl O �aa to t\ m V' n m V/ "C m n N .fir CT z CT !� O Q N n Q m V1 Vl M W Vi U y d m N •�'. n m m V1 M Vt Ot m C1 O t' n o t' crr° C I N CT m ^ ELO to O O O O U in c�c M ry v TJ Q a c `o ° �J �) W 7 0 0 o O Ca G o a 0 o N `L �O Vt m V1 O N _ ry LUWi r M t O O�v�O m.0N N � C Cl c y U c c O .- U V V u L W w _ s• to o M rn�o v m m m c o rn c.O W N 2 n o n C CJS n m Q' M Q O O z O n N M N V`liut Cn U nt M ry a C cr�m � inh N m co�O M N Vl y� Cy O m rnnmmmnn C L4-- mtn mmNon o � c M O c Qui-N m v v N Q) d m 0) d1E 0 (� c ti+ art M ur vs vi u 4-J t 0 E C o2 a c u _ mmm to N N rn o U �N O�n N C Vt N ut n ry ^^L` N O rn �D O n..�-•i o ri CJ o t•1 � ° � m � ¢J w o - W C = � fu �vN CT y' 1D m N ti N Q C R N W Vi .j..J C C m"r m ti rD m m rD a'V1 ol 1p oro �m mcovr�vt� m o U— N U [' m -m n V M ri O N cl mn C MrD(TU m mNomNv�nvoo C c u o v ao v a r z 0 co m c N U c � •• M m c � Wim. m � 0 0 a �• a E�, a, O N W L a O > > C 1O � rn m E n ate+ OJ Q) 1C0 W Q/ - d 0- C u Y Y y o L E c o H� ~ce >w v v w v C u= 12 1 CT ois O) C U C3"" N au a v Eau'nS�U' ABYani U moy � E0 me m'pO Lo Eo u��t n � N N-\ OIO VIvvSC N BTU CC � C OO � O0L. v c c v o` v v 2 v '-' o0 >•c`- EEvm v oo T� EEvm c �incm o N C m a E Y v v v m ,toia m E.x v d _ iri¢a U o a v U U� W "-Li C U U� Q W JLL P. V U u m v W E c ai v v o r v M m E c o v v v o m m>jriw��K�rr� V1 m»u.w5��K�H z" WILLIAM .4WALKER, M. D. OFFICE OF THE HEALTH SERVICES DIRECTOR h, „. DIRECTOR 50 Douglas Drive,Suite 310-A Martinez,California CONTRA COSTA 94553 --- Ph(925)957-5405 _ HEALTH SERVICES Fax(925)957-5401 March 7,2008 Federal Glover, Supervisor District 5 John Gioia, Supervisor District 1 Chair, Contra Costa Board of Supervisors Contra Costa Board of Supervisors 315 E. Leland Road 11780 San Pablo Avenue#D Pittsburg CA 94565 El Cerrito CA 94530 Dear Supervisors Glover and Gioia: During the meeting of the Professional Affairs Committee of the Contra Costa Regional Medical Center of February 21, 2008, you requested comparative information concerning the hospital's employee benefit package relative to other area hospitals. The following is an attempt to be responsive to that request. Summary: Employee Benefits as a percent of salary (excluding OPEB Liability) Fiscal Year Ending 2006: Contra Costa Regional Medical Center: 81.70% Alameda County Medical Center: 62.22% Santa Clara County Medical Center: 59.18% Doctors Hospital San Pablo: 44.20% John Muir-Walnut Creek Campus: 48.25% John Muir-Concord Campus: 47.22% All hospitals in California are required to annually report detailed financial and utilization data to the Office of Statewide Health Planning and Development(OSHPD). This report is based on a uniform reporting system (i.e., all hospital reports are prepared in a uniform manner,using OSHPD definitions). Hospitals are required to submit reports, within four months of the close of their accounting period. After receipt by OSHPD they are desk audited, and the corrected data are input into the OSHPD database. In addition, if individual hospitals wish to revise their data they may. Periodically (at least annually), data files are posted on the OSHPD website. The most recent file available on the website covers hospital accounting periods ending during 2006. According to the Accounting and Reporting Manual for California Hospitals, which governs the reporting system, employee benefits are defined as, "A pension provision,retirement allowance, =" i'..,.N • Contra Costa Alcohol and Other Drugs Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health• Contra Costa Health Plan • Contra Costa Hazardous Materials Programs •Contra Costa Mental Health• Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers I Federal Glover,Supervisor District 5,Chair John Gioia,Supervisor District 1 Contra Costa Board of Supervisors March 7,2008 Page 2 insurance coverage,paid vacation, sick leave, and holiday time off or other cost representing a present or future return to an employee,which is neither deducted on a payroll nor paid for by the employee." The OSHPD data should be viewed within the context of being self-reported and unaudited. There are no consequences for erroneously filed reports. Accordingly, we contacted Doctors Hospital, Santa Clara Valley Medical Center and Alameda Medical Center to validate and confirm the salary and benefit numbers contained on the attached schedule were accurate. All facilities either corrected or validated the numbers contained on the schedule. The John Muir Concord and John Muir Walnut Creek data are taken directly from publicly filed OSHPD statements. The data are believed to be accurate but due to timing constraints independent validation did.not occur. Please note OSHPD data does not provide Salary and Benefit information at the detailed employee classification level, e.g.Nursing. Please advise if additional information or clarification is required. Sincerely, Patrick Godley Chief Operating Officer/Chief Financial Officer Contra Costa Health Services cc: William Walker, M.D., CCHS Director and Health Officer Jeff Smith,M.D., CCRMC and Health Centers Executive Director John Cullen,County Administrator Lisa Driscoll. 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Majilcthise : Health I rison Page 1 0� J P Majikthise By Lindsay Beyerstein, freelance journalist. June ii, 2005 Health in prison Now they tell us.Too bad New York just renewed Prison Health Service's contract for a third of a billion dollars: Inmates'Medical Care Failing in Evaluation by Health Dept. A recent evaluation of the company in charge of inmate health care at Rikers Island, coming months after it was awarded a new$300 million contract,has found that it has failed to meet a number of the most basic treatment goals.City records showed that the company,Prison Health Services Inc.,did not meet standards on practices ranging from H.I.V.and diabetes therapy to the timely distribution of medication to adequately conducting mental health evaluations. The city Department of Health and Mental Hygiene,which oversees the company's work at Rikers Island and at a jail in Lower Manhattan,found that during the first quarter of 2005, Prison Health failed to earn a -....passing grade on 12 Of 39 performance-standards:the city sets.for treating jail inmates.Some.of the problems, like incomplete"medical.records or slipshod evaluations of mentallyill inmates,have been evident since 2004 but have not been corrected,according to health department reports. Other problems identified in the department's review,involving things as serious as the oversight of inmates who have been placed on suicide watch,are more recent or had not been evaluated by city health auditors in the past. As a result,the city is withholding$55,000 in payments to the company,the largest penalty for poor performance it has incurred since 2001,the first year of its work in New York City adult jails. [NYT] Speaking of health care in prison,I've been meaning to recommend The New As ly ums;Frontline's documentary about mental services in prison.The main focus is on Ohio's new prison-based psychiatric system.The Frontline crew got unprecedented access to film prison officials,health care providers, and inmates in Ohio's maximum security prisons. Much of the footage is very disturbing.There's an incredibly poignant scene of a psychiatrist running a therapy group for ten guys in individual cells.The doe runs the group from rolling chair in the hall.The scene is especially poignant because he does such a good job,given the constraints of the setup. Everyone's really giving there all to this group,but you know that even if it works,it can't really help.These guys are deeply disturbed maximum security inmates whose mental health only matters to officials insofar as it improves their disciplinary records. Posted by Lindsay Beyerstein at 07:04 AM in Law,Medicine I Permalink TrackBack TrackBack URL for this entry: http://www.typepad.com/t/trackback/24039/2626946 Listed below are links to weblogs that reference Health in prison: Majikthise : Health in prison Page 2 of 2 Comments Jesus Lindsay,how naive can you be!They don't care about access to or quality of healthcare for the average American,you don't really expect them to care about it for those in[non white collar]prisons,do you? Posted by:Ol Cranky I Junei1,20_05 at o4_44 AM Nope.Nobody cares about prisoners much.On the other hand New Yorkers don't like getting ripped off on general principle. So there's a wedge there. The Frontline documentary is interesting because the people running the Ohio program do seem to care quite a bit--at any rate,much more than I'd expect of a psych staff in a supermax prison. Ohio ended up with so many crazy people in their prisons that they had to create a separate psychiatric system within their maximum and supermax prisons.This goes beyond the state hospital for the criminally insane.It's an entire prison system for people with ongoing psychiatric disease.About 16%of the general population in Ohio has a major psychiatric illness(i.e. bipolar,schizophrenia,etc.). Posted by:Lindsay Bg ery stein I June 11.2oos at 11:10 AM What's so interesting about the group therapy scene is that the shrink is doing such a great job of delivering therapy whose core assumptions are inconsistent with prison(your feelings matter,we care about you as an individual,we're here to support each other...).Neither he nor the prisoners seem to realize the inconsistency.So,at least in the moment,the disconnect doesn't matter. Posted by:Lindsay Beerstein I June 11,20os at 11:2o AM Health system is big problems in all over the world in my country the health department has declared the existing rate'contract for the purchase of medicine five year ago but still yet we no receive any progress in this matters. Posted by:Andrew Spark I February10,2oo6 at o3:31 AM /,merican Civil Liberties Union:ACLU and PJC Urge Maryland... http://www.aclu.org/prison/gen/14742prs20050 html �A MEMBER OFIU- r r• URL:http:/hrvw.adu.org/prisorJgerv14742prs20050601.html ACLU and PJC Urge Maryland Board to Reject Contract with Company Known for Providing Deficient Medical Care in Prisons(6/1/2005) FOR IMMEDIATE RELEASE Contact: media@aclu.org ANNAPOLIS, MD -- Citing Correctional Medical Services' poor record for dispensing medical care to prisoners, the American Civil Liberties Union and Public Justice Center today urged Maryland's Board of Public Works to reject a proposed contract with the for-profit company. "Correctional Medical Services' history of cutting corners to maintain profits jeopardizes the lives of thousands of incarcerated people across the country," said Elizabeth Alexander, Director of the ACLU's National Prison Project. "Many states have already learned a painful lesson from their dealings with Correctional Medical Services. Maryland must avoid handing over the care of its prisoners and jail detainees to a company with a disastrous reputation." Correctional Medical Services (CMS) currently holds contracts in 27 states. In Michigan, where the company provides care to prisoners statewide, CMS has come under heavy scrutiny for its attempts to save money by limiting prisoners' referrals to outside medical specialists. A federal court found that excessive delays in providing prisoners with referrals contributed to three deaths during an 18-month period. Five other prisoners who died during the same time period also experienced significant delays in treatment. Last week, the Maryland Board of Public Works announced that at a meeting today it will review for approval a two-year statewide medical services contract between the state's Department of Public Safety and Correctional Services and CMS. The new contract is scheduled to begin July 1, 2005. Under the new contract; CMS would provide care to more than 4,000 detainees confined at the Baltimore City Detention Center, which has come under fire in recent years for providing deficient medical care. In August 2002, the U.S. Department of Justice cited the jail for 107 violations of health and safety standards. Since 2002, the ACLU and Public Justice Center have been involved in litigation about the medical care provided at the Baltimore Jail by the current for-profit medical and mental health care provider, Prison Health Services. Even with the significant rise in spending for the new contract, according to the state's estimates, health services are still under funded by several million dollars. The ACLU and Public Justice Center expressed concern that simply switching for-profit providers without increasing resources to fund treatment and maintaining close contract oversight will leave detainees with the same poor care they received under Prison Health Services. "There is little point in changing company names if the continuation of inadequate funding and indifference from the state regarding detainee health remains the same," said Sally Dworak-Fisher, an attorney with the Public: Justice Center. "In an environment without consistent outside oversight and inspection, the motivations of for-profit companies like CMS and Prison Health Services become dangerous. Cutting corners to preserve profits but risk the health and lives of detainees is inexcusable, and Maryland officials are responsible when the care is constitutionally inadequate." Today's hearing before Maryland's Board of Public Works will be held at 10:00 AM in the Governor's Reception Room, 2nd floor of the Annapolis State House. 1 of 2 4/7/08 10:50 PM American Civil Liberties Union:ACLU and PJC Urge Maryland... http://www.aclu.org/prison/gen/l 4742prs20050601 .html ©ACLU,125 Broad Street,18th Floor New York,NY 10004 This is the Web siteof the American Civil Liberties Union and the ACLU Foundation. Learn more about the distinction between these two components of the ACLU. User Agreemen I Privacy Statenien I FAQs I Site Mao 2 of 2 4/7/0810:50 PM I AT&T Yahoo!Mail-judeseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=In... Al �. Print-Close Window Classic Date: Mon,7 fpr 2008 23:00:49-0700(PDT) From: "Judith Jones"<judeseven@sbcglobal.net> To: "Judith Seba Jones"<Judeseven@sbcglobal.net> E-mail this to a friend Healthcare Behind Bars by Duwayne E;;cobedo Robert Boggon suffers a mental episode in a Dollar Tree store, which leads to his incarceration in the Escambia rr, County jail. Despite at one point rocking on the floor of his cell and urinating on himself and displaying other odd behaviors, Boggon never receives a psychiatric evaluation during the 11 days he spends in the jail and only receives medication used to calm him down before his death Aug. 29, records and testimony reveal. Jail guards end up dragging the 65-year-old trucker from his cell to the shower, stripping him, shocking his wet body with a Taser Gun, then strapping his lifeless body to a restraining chair, wrapping a towel around his head and returning him facing the back of his cell several hours before he's found dead, a civil suit by Boggon's family alleges. Hosea Bell, a homeless man, gets arrested Aug. 9 for urinating on a sidewalk outside Weis Elementary School. He's found mentally incompetent by a judge to stand trial Nov. 30 but 11 days later the 55-year-old is taken in handcuffs by a police car to Sacred Heart Hospital after appearing lethargic at the Escambia County jail. He dies at the hospital a few hours later. Both cases are focusing the spotlight on healthcare provided to inmates at the Escambia County jail by Prison Health Services, the nation's largest for-profit inmate healthcare company, caring for about one in every 10 people behind bars. Across Florida and the country the company based outside Nashville has come under fire the past year for spotty and sometimes lethal care. Following the Boggon and Bell cases, the quality of the company's medical services is coming under fire locally. David Craig, the Community Law Enforcement Oversight president, is blunt and concise in his assessment of Prison Health Services medical care for inmates. "Given their less than stellar record, CLEO feels they would be more accurately named Prison Death Services," he says. Todd LaDouceUr, the Boggon family's attorney, says the federal wrongful death lawsuit may soon extend to Prison Health Services. It currently only names two of the company's nurses individually, Lisa Whitlock and Elaine Gregory. "I've been through the Florida Department of Law Enforcement investigation and it appears Mr. Boggon never saw a doctor in his 11 days in jail," the civil rights attorney says. "Clearly, from everybody's testimony, this was someone who needed to see a doctor. I'm not sure how that works. There may be medical negligence here. The family is very concerned about his treatment and we don't want to close that avenue." Sharon Giraud, a Mental Health Association of West Florida client advocate, says for years it has documented a number of cases that have alerted it to the possibility of systemic problems in the jail system's treatment, especially of the mentally ill. "We are still very concerned," Giraud says. "There's all this publicity on a regular basis. We need special training to help them and law enforcement deal with mentally ill people." Escambia County Jail Director Dennis Williams helped privatize inmate healthcare after Sheriff Ron McNesby took office in 2000, saying at the time that the jail's healthcare system then was fraught with deficiencies. Williams defends Prison Health Services, which currently is paid about $3.8 million to provide healthcare to Escambia County's jail. "For Escambia County, they're doing very well," he says. "That's not to say there aren't places we could improve or that we get things right 100 percent of the time." PRISON HEALTH'S RECORD Prison Health Services is no stranger to controversy. Currently, it serves more than 310 jail and prison sites around the country, covering approximately 214,000 inmates in 37 states. The Atlanta Journal-Constitution reported in December in a story on Prison Health that twice in the past four months, the Gwinnett County jail was sued by the families of inmates who died in controversial Taser-related scuffles with deputies. During the same: period, two other inmates died—one killing himself with a metal jail key and the other dying in her cell, while her cellmates begged for medical care, the Atlanta paper found. In Mississippi, the American Civil Liberties Union sued the company this summer, alleging that inmates of a Mississippi prison were misdiagnosed and received poor care. The New York Times conducted a yearlong investigation of Prison Health Services, which has a $254 million contract in New York City, and reported its findings last February in a three-part series. The report found in two New York City jail deaths, and eight others across upstate New York, state investigators kept discovering the same failings: medical staffs trimmed to the bone, doctors underqualified or out of reach, nurses doing tasks beyond their training, prescription drugs withheld, patient records unread and employee misconduct unpunished. In addition, the New York Times reported that substandard care by the company contributed to at least 15 inmate deaths in 11 Florida jails since 1992. Several inmate deaths in Florida cost Prison Health Services three county contracts, millions of dollars in settlements, and an apology For its part in the 1994 death of Diane Nelson. The 46-year-old was jailed in Pinellas County on charges of 3 4/7/08 11:01 PM AT&T Yahoo!Mail-ju-Jeseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=ln... t that she had :clapped her teenage daughter. She suffered a heart attack after nurses failed for two days to order the heart medication her private doctor had prescribed. In that case, the New York Times reports as Nelson collapsed, a nurse told her, "Stop the theatrics." The same nurse admitted later in a deposition that she had joked to the jail staff, "We save money because we skip the ambulance and bring them rig)t to the morgue." In 2004, a wornan in the Hillsborough County jail sued Prison Health Services, blaming the company for the death of her newborn son from complications during delivery. The baby was born over an infirmary toilet at the Falkenburg Road jail. And in Tallahassee, the family of Ruth Hubbs, who died at the Leon County Jail infirmary, recently earned a $350,000 settlement from Prison Health Services. The 39-year-old Hubbs, who suffered from bipolar disorder and drug addiction was found dead in the infirmary May 16, 2003, about a day after deputies reported seeing her sitting on the floor of her jail cell shirtless and yelling incoherently to herself. The company failed to take her blood levels, monitor or administer drugs she was prescribed and ignored red flags raised by a therapist and two jail guards. LAWMAKERS WARY Still, Prison Health earlier this month won the Florida Department of Corrections contract to provide healthcare to about 14,000 inmates in 13 South Florida prisons. The state will pay the company $792 million over 10 years. The company's track record made some lawmakers wary, newspapers reported in South Florida. "It all seems very suspect," Sen. Frederica Wilson, a Miami Democrat who sits on legislative panels dealing with criminal justice and corrections issues, told the South Florida Sun Sentinel. "We know the health care in the prisons already isn't what it should be. If this company is going to under-bid all the others, then I fear we can only expect greater disappointment." Florida Justice Institute Executive Director Randy Berg, who has fought for prisoners' rights for 28 years, has battled the company tNice for refusing to provide needed medical care to inmates and followed the company closely. "They have a bad history of providing healthcare to inmates," Berg says in a telephone interview with the Independent News from his Miami headquarters. "It's an odd situation. The less healthcare they provide the inmate population, the more money they make. Its profit motives have always concerned me." Michael Catalano, chairman, president and chief executive of America Service Group, which owns Prison Health Services, defends the company's service. He argues that the company actually reduces costs and improves the quality of care. Catalano and company officials say its successes far outnumber failures and its policy is never to deny necessary medical care. And they say complaints result from the challenging work of inmate healthcare have mainly come from litigious inmates, disgruntled employees and overzealous investigators. "(Our employees) choose to render a vital public health service in their own communities," Catalano says in a statement. "This is a high calling. Our patients must always receive appropriate medical care. There can be no compromise of this fundamental value. Our vision is to lead the correctional healthcare field in reputation and results, achieving the highest standards of operational excellence, clinical quality and client service." MEDICAL RESPONSE A check of Escambia County Circuit Court records found two cases involving Prison Health Services, since it took over Escambia inmate medical care in 2001. In federal civil suits filed in the Northern District of Florida, 27 cases were filed against the company since 1995, records show. The suits, many of which were dismissed for various reasons, largely tell of medications allegedly being withheld or claims of treatments of injuries being denied. During the Coroner's Inquest into Boggon's death last month, one corrections officer testified that Boggon "seemed to have a lot of mental health issues. He didn't seem to respond." Whitlock, a Prison Health nurse who found Boggon dead, testified that a counselor did see him. But Kimberly Cox, a corrections officer at the jail and a great niece of Boggon's, testified that a day before his death Prison Health nurses acted uninterested in her plea for them to order a psychiatric evaluation, which she said she was told had not been done. Whitlock said on the stand at the Coroner's Inquest that Boggon would "bite, yell or spit,"which prevented nurses from getting a complete diagnosis of him. "He was very uncooperative," she testified. "He was only in there nine days. We were trying to help him. We did give him medication." Sources close to the Bell case, say his pleas for medical attention went unheeded at the Escambia County jail, until corrections officers noticed a "major change." Once transported to Sacred Heart, repeated requests of Prison Health Services from the hospital for Bell's medical records were ignored, sources say. No lawsuit has been filed to date in Bell's case. Complaints of poor treatment, especially of the mentally ill, are not new to Escambia County jail. In 2003, Pensacola Junior College (Police Chief Nancy Newland, then on the board directors of the Mental Health Association of West Florida, called on the jail to improve its healthcare services and training of jail employees. Newland's brother, Harold Newland II, a paranoid schizophrenic, died in September 2002, shortly after being release from jail. Newland says he was denied his prescribed medicine while in jail, despite her waiting two hours to meet with a jail employee to bring his doctor's prescription and medication to the jail. Without proper medication, schizophrenics' condition rapidly deteriorates and they exhibit bizarre behavior that might lead to further criminal charges. BETTER HEALTHCARE? More than two vears later, Lakeview Center and the Mental Health Association are working with the Escambia County jail of 3 4/7/08 11 :01 PM AT&TYahoo!Mail-judeseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=In... 1 and other law enforcement agencies to implement a 40-hour training program started in Seminole County that creates Crisis Intervention Teams to better handle mentally ill people. The Escambia County jail is planning on sending five corrections officers through the training in the beginning. The training includes a virtual reality schizophrenic machine, which allows police officers and others to experience what its like to suffer from the disorder. Williams admits the jail is reviewing its handling of inmates after the Boggon and Bell cases. But he points out that Prison Health Services, as required by its contract with Escambia County, has earned and maintained national accreditation since 2003. "We have reviewed our process," he says. "But are we doing anything that requires dramatic change? I don't think so." duwayne inweekly.net f3 4/7/08 11:01 PM I AT&TYahoo!Mail-judeseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=ln... ,apj Q M A I L Print-Close Window G?a>;':c Date: Mon,7 Apr 2008 23:00:49-0700(PDT) From: "Judith Jones"<Judeseven@sbcglobal.net> To: "Judith'Seba Jones" <Judeseven@sbcglobal.net> E-mail this to a friend Healthcare Behind Harr by Duwayne Escobedo Robert Boggon suffers a mental episode in a Dollar Tree store, which leads to his incarceration in the Escambia County jail. Despite at one point rocking on the floor of his cell and urinating on himself and displaying other odd IjP behaviors, Boggon never receives a psychiatric evaluation during the 11 days he spends in the jail and only receives medication used to calm him down before his death Aug. 29, records and testimony reveal. Jail guards end up dragging the 65-year-old trucker from his cell to the shower, stripping him, shocking his wet body with a Taser Gun, then strapping his lifeless body to a restraining chair, wrapping a towel around his head and returning him facing the back of his cell several hours before he's found dead, a civil suit by Boggon's family alleges. Hosea Bell, a homeless man, gets arrested Aug. 9 for urinating on a sidewalk outside Weis Elementary School. He's found mentally incompetent by a judge to stand trial Nov. 30 but 11 days later the 55-year-old is taken in handcuffs by a police czar to Sacred Heart Hospital after appearing lethargic at the Escambia County jail. He dies at the hospital a few hours later. Both cases are focusing the spotlight on healthcare provided to inmates at the Escambia County jail by Prison Health Services, the nation's largest for-profit inmate healthcare company, caring for about one in every 10 people behind bars. Across Florida ,and the country the company based outside Nashville has come under fire the past year for spotty and sometimes lethal care. Following the Boggon and Bell cases, the quality of the company's medical services is coming under fire locally. David Craig, the Community Law Enforcement Oversight president, is blunt and concise in his assessment of Prison Health Services medical care for inmates. "Given their less than stellar record, CLEO feels they would be more accurately named Prison Death Services," he says. Todd LaDouceUr, the Boggon family's attorney, says the federal wrongful death lawsuit may soon extend to Prison Health Services. It currently only names two of the company's nurses individually, Lisa Whitlock and Elaine Gregory. "I've been through the Florida Department of Law Enforcement investigation and it appears Mr. Boggon never saw a doctor in his 11 days in jail," the civil rights attorney says. "Clearly, from everybody's testimony, this was someone who needed to see a doctor. I'm not sure how that works. There may be medical negligence here. The family is very concerned about his treatment and we don't want to close that avenue." Sharon Giraud, a Mental Health Association of West Florida client advocate, says for years it has documented a number of cases that have alerted it to the possibility of systemic problems in the jail system's treatment, especially of the mentally ill. "We are still very concerned," Giraud says. "There's all this publicity on a regular basis. We need special training to help them and law enforcement deal with mentally ill people." Escambia County Jail Director Dennis Williams helped privatize inmate healthcare after Sheriff Ron McNesby took office in 2000, saying at the time that the jail's healthcare system then was fraught with deficiencies. Williams defends Prison Health Services, which currently is paid about $3.8 million to provide healthcare to Escambia County's jail. "For Escambia County, they're doing very well," he says. "That's not to say there aren't places we could improve or that we get things right 100 percent of the time." PRISON HEALTH'S RECORD Prison Health Services is no stranger to controversy. Currently, it serves more than 310 jail and prison sites around the country, covering approximately 214,000 inmates in 37 states. The Atlanta Journal-Constitution reported in December in a story on Prison Health that twice in the past four months, the Gwinnett County jail was sued by the families of inmates who died in controversial Taser-related scuffles with deputies. During the same period, two other inmates died—one killing himself with a metal jail key and the other dying in her cell, while her cellmates begged for medical care, the Atlanta paper found. In Mississippi, the American Civil Liberties Union sued the company this summer, alleging that inmates of a Mississippi prison were misdiagnosed and received poor care. The New York Times conducted a yearlong investigation of Prison Health Services, which has a $254 million contract in New York City, and reported its findings last February in a three-part series. The report found in two New York City jail deaths, and eight others across upstate New York, state investigators kept discovering the same failings: medical staffs trimmed to the bone, doctors underqualified or out of reach, nurses doing tasks beyond their training, prescription drugs withheld, patient records unread and employee misconduct unpunished. In addition, the New York Times reported that substandard care by the company contributed to at least 15 inmate deaths in 11 Florida jails since 1992. Several inmate deaths in Florida cost Prison Health Services three county contracts, millions of dollars in settlements, and an apology for its part in the 1994 death of Diane Nelson. The 46-year-old was jailed in Pinellas County on charges of 3 4/7/08 11:01 PM AT&T Yahoo!Mail-judeseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=In... that she had slapped her teenage daughter. She suffered a heart attack after nurses failed for two days to order the heart medication her private doctor had prescribed. In that case, the New York Times reports as Nelson collapsed, a nurse told her, "Stop the theatrics." The same nurse admitted later in a deposition that she had joked to the jail staff, "We save money because we skip the ambulance and bring them right to the morgue." In 2004, a woman in the Hillsborough County jail sued Prison Health Services, blaming the company for the death of her newborn son from complications during delivery. The baby was born over an infirmary toilet at the Falkenburg Road jail. And in Tallahassee, the family of Ruth Hubbs, who died at the Leon County Jail infirmary, recently earned a $350,000 settlement from Prison Health Services. The 39-year-old Hubbs, who suffered from bipolar disorder and drug addiction was found dead in the infirmary May 16, 2003, about a day after deputies reported seeing her sitting on the floor of her jail cell shirtless and yelling incoherently to herself. The company failed to take her blood levels, monitor or administer drugs she was prescribed and ignored red flags raised by a therapist and two jail guards. LAWMAKERS WARY Still, Prison HE�alth earlier this month won the Florida Department of Corrections contract to provide healthcare to about 14,000 inmates in 13 South Florida prisons. The state will pay the company $792 million over 10 years. The company's track record made some lawmakers wary, newspapers reported in South Florida. "It all seems very suspect," Sen. Frederica Wilson, a Miami Democrat who sits on legislative panels dealing with criminal justice and corrections issues, told the South Florida Sun Sentinel. "We know the health care in the prisons already isn't what it should be. If this company is going to under-bid all the others, then I fear we can only expect greater disappointment." Florida Justice Institute Executive Director Randy Berg, who has fought for prisoners' rights for 28 years, has battled the company twice for refusing to provide needed medical care to inmates and followed the company closely. "They have a bad history of providing healthcare to inmates," Berg says in a telephone interview with the Independent News from his Miami headquarters. "It's an odd situation. The less healthcare they provide the inmate population, the more money they make. Its profit motives have always concerned me." Michael Catalano, chairman, president and chief executive of America Service Group, which owns Prison Health Services, defends the company's service. He argues that the company actually reduces costs and improves the quality of care. Catalano and company officials say its successes far outnumber failures and its policy is never to deny necessary medical care. And they say complaints result from the challenging work of inmate healthcare have mainly come from litigious inmates, disgruntled employees and overzealous investigators. "(Our employees) choose to render a vital public health service in their own communities," Catalano says in a statement. "This is a high calling. Our patients must always receive appropriate medical care. There can be no compromise of this fundamental value. Our vision is to lead the correctional healthcare field in reputation and results, achieving the highest standards of operational excellence, clinical quality and client service." MEDICAL RESPONSE A cheek of Escambia County Circuit Court records found two cases involving Prison Health Services, since it took over Escambia inmate medical care in 2001. In federal civil suits filed in the Northern District of Florida, 27 cases were filed against the company since 1995, records show. The suits, many of which were dismissed for various reasons, largely tell of medications allegedly being withheld or claims of treatments of injuries being denied. During the Coroner's Inquest into Boggon's death last month, one corrections officer testified that Boggon "seemed to have a lot of mental health issues. He didn't seem to respond." Whitlock, a Prison Health nurse who found Boggon dead, testified that a counselor did see him. But Kimberly Cox, a corrections officer at the jail and a great niece of Boggon's, testified that a day before his death Prison Health nurses acted uninterested in her plea for them to order a psychiatric evaluation, which she said she was told had not been done. Whitlock said on the stand at the Coroner's Inquest that Boggon would "bite, yell or spit," which prevented nurses from getting a complete diagnosis of him. "He was very uncooperative," she testified. "He was only in there nine days. We were trying to help him. We did give him medication." Sources close to the Bell case, say his pleas for medical attention went unheeded at the Escambia County jail, until corrections officers noticed a "major change." Once transported to Sacred Heart, repeated requests of Prison Health Services from the hospital for Bell's medical records were ignored, sources say. No lawsuit has been filed to date in Bell's case. Complaints of poor treatment, especially of the mentally ill, are not new to Escambia County jail. In 2003, Pensacola Junior College Police Chief Nancy Newland, then on the board directors of the Mental Health Association of West Florida, called an the jail to improve its healthcare services and training of jail employees. Newland's brother, Harold Newland II, a paranoid schizophrenic, died in September 2002, shortly after being release from jail. Newland says he was denied his prescribed medicine while in jail, despite her waiting two hours to meet with a jail employee to bring his doctor's prescription and medication to the jail. Without proper medication, schizophrenics' condition rapidly deteriorates and they exhibit bizarre behavior that might lead to further criminal charges. BETTER HEALTHCARE? More than two years later, Lakeview Center and the Mental Health Association are working with the Escambia County jail ?of 3 4/7/08 11:01 PM AT&TYahoo!Mail-jLideseven@sbcglobal.net http://us.f822.mail.yahoo.com/ym/ShowLetter?box=ln... and other law enforcement agencies to implement a 40-hour training program started in Seminole County that creates Crisis Intervention Teams to better handle mentally ill people. The Escambia County jail is planning on sending five corrections officers through the training in the beginning. The training includes a virtual reality schizophrenic machine, which allows police officers and others to experience what its like to suffer from the disorder. Williams admits the jail is reviewing its handling of inmates after the Boggon and Bell cases. But he points out that Prison Health Services, as required by its contract with Escambia County, has earned and maintained national accreditation since 2003. "We have reviewed our process," he says. "But are we doing anything that requires dramatic change? I don't think so." duwa)ine inweekl .net F3 4/7/08 11:01 PM Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 1 of 8 Display full version DEMOCRACY SII THE WAX ARID PtACB *RPORT March 04, 2005 Harsh Medicine: New York Times Exposes How 6 N Private Health Care in Jails Can Be a "Death Sentence" for Prisoners �� We take an in-depth look at the for-profit health care in prison and jails in this country. The New York Times published a series titled "Harsh Medicine" based on a yearlong investigation of Prison Health Services, the nation's largest for- profit provider of prisoner medical care, that exposes how inadequate care has resilted in death and suicides by prisoners. [includes rush transcript] Today, we are going to take an in-depth look at for-profit health care in prison and jails in this country. Prison Health Services or PHS is the nation's largest for-profit --- - - ----- provider of inmate medical care-a 2 billion dollar_a year.industry. They have 86 contracts in 28 states and care for 237,000 inmates-which is one in every 10 people who are incarcerated. Earlier this week, the New York Times published a series, titled "Harsh Medicine." The articles, based on a yearlong investigation of PHS, expose how the company provided medical care that was widely inadequate in some cases-and deadly in others. The articles detail a range of problems with PHS" medical services-some of which resulted in death or suicides by inmates. The list of problems include: skeletal medical staffs, under qualified doctors and nurses, doctors who were practicing without proper certification, prescriptkgn drugs being withheld from patients, and employee misconduct that went unpunished. PHS began receiving contracts in New York State over the last decade despite a tarnished record of providing care in Florida and Pennsylvania. Since then, the State Commission of Corrections has faulted the company in 23 inmate deaths and has recommended disciplinary action of PHS doctors and nurses, 15 times in the past four years. The New York Times notes that in one report, the chairman of the commission's medical review board-Frederick C. Lamy-labeled the company, "reckless and unprincipled in its corporate pursuits, irrespective of patient care." Despite this, New York City renewed PHS' contract in January of this year. PHS declined to make someone available for our program but they sent us a statement which reads in part-"since the story appeared, PHS has received calls from clients around the country and every one has been supportive and expressed their disagreement with the Times coverage." • Paul von Zeilbauer, reporter for the New York Times. Wrote series Harsh medicine about the severe deficiencies of Prison Health Services. PHS is a private company that provides health care to prisons and jails all over the country. • Dr. Bobby Cohen, federal court appointed doctor who monitors health care in prisons and jails in Michigan, Ohio, Connecticut and New York. • Barbara Ferguson, sister of Brian Tetrault . Inmate with Parkinson's disease who, she alleges, was denied proper medical care and died behind bars. PHS f Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 2 of 8 was the health care provider in the jail that Brian was locked up in. This transcript is available free of charge. However, donations help us provide closed captioning for the deaf and hard of hearing on our TV broadcast. Thank you for your generous contribution. Donate - $25, $50, $100, More... AMY GOODMAN: Joining us in our studio is Paul von Zeilbauer, the reporter who wrote the series in The New York Times, and Dr. Bobby Cohen, who monitors prison health care for federal courts. On the phone with us from Clearwater, Florida, Barbara Ferguson, whose brother died in a jail cell because he was denied proper treatment by P.H.S. staff, she alleges. We welcome you both and all of you to Democracy Now! Paul von Zeilbauer, this is quite an astounding series. Lay out for us what you exposed. PAUL VON ZEILBAUER: Okay. Well, over the course of about 15 months, 12 to 15 months, I began looking at the jail medical—the medical—the system of delivering medical care in the New York City jail system where P.H.S. is the medical provider, and there was a serles of suicides that occurred in the first half of 2003, and I wrote, I believe, one or two articles, one of which was about how two of these six suicides were people who were on suicide watch at the time, which, you know, brings up the obvious question of what is suicide watch and how does that happen. And from there, we began looking at who the actual provider is, Prison Health Services being the contractor, and then from there, I think it just sort of naturally took a little bit of flight. When you wonder who is doing the medical care, and you begin looking at where else they provide it. And as it turns out, you know, they have had contracts with upstate jails, and of course, they're a large company, so they have had many other contracts that we just began looking at. And finding other problems, you know, around the country. And that's how it began, and then, you know, like any gcod story, the details lead to other details, and you begin opening doors,-and that's haw everything sort of came to light over time. JUTAN GONZALEZ: And you originally got on the story because you were covering some of those deaths as part of your regular beat, or how did you get actually involved yourself in the story? PAUL VON ZEILBAUER: Yes. Right. My job is—in the metropolitan desk at the Times is covering prisons, jails. So Rikers Island was sort of the centerpiece of my beat, if you want to call it that. And so when these suicides occurred, like I said, in the first half—six in the first half of 2001 which may not sound like a lot, but in the world of Rikers Island, it was a lot. In fact, I think I mention in the story, it was the largest—the highest rate of suicide in any six-month period since I think 1985. So, it was remarkable that it occurred, and my beat was covering the jail system and, you know, it became something obviously to look at. AMY GOODMAN: Tell us about Jose Cruz? PAUL VON ZEILBAUER: Jose Cruz. Jose Cruz, if I remember correctly, was the first of the six people who killed themselves in this six months period, to do so in January, I believe, of 2003. And, let me see, I don't want to get any details wrong, but I believe Jose Cruz was a man who was arrested for an assault. He was HIV positive. I believe he had tuberculosis. He was in the—how do you call—it's called Maui in the vernacular. How do you refer to—? 1 Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 3 of 8 DR. BOBBY COHEN: One of the infirmaries. PAUL VON ZEILBAUER: Yeah, he was in an infirmary, because he was contagious. And he was also put on suicide watch, because he had become despondent over time. What occurred, if you just want me to give—I can give a quick history of what happened to him. He was put in a cell in this medical lockdown unit that was at the end of the wing where guard—where the jail officers couldn't visually see him unless they walked down and actually looked into his cell. So, while he was on suicide watch, he was effectively out of sight. And he used that opportunity, apparently, to kill himself. AMY GOODMAN: I wanted to turn to Barbara Ferguson. If you could tell us the story of your brother. What happened to Brian Tetrault. BARBARA FERGUSON: Yeah, Brian Tetrault. Good morning. My brother in November of 2001 made the mistake of going to his ex-wife's house and taking some things he thought belonged to him. She pressed charges and had him arrested. My family and I, who live in Florida, had no knowledge of this at the time. Ten days later, I got a phone call at my house from his ex-wife that my brother died. My brother was very, very sick, very ill. He had undergone some surgeries and things to improve his life, quality of life, but he was an obvious ill person. We were -vE:ry confused. We had no idea, you know, what had happened. And it wasn't really until Paul had come to meet with us in last July that I was able to put together the whole story. We didn't—we were lied to by his ex-wife about how he had gotten into jail. We found out exactly how that happened. But we didn't understand why he would have died there, and so when we started to pursue some of the information that we wanted, my parents did through the Freedom of Information Act, we got more confused. Just didn't make sense. Excuse me. As, you know, it got harder and harder to get more information, and also being in Florida, it made it harder for us to try to figure it out. And at one point, my parents tried to be the party to act on my brother's behalf to, you know, allege a suit against the jail, because we knew that something had happened, and in that pursuit, my nephew was named the person who would do that, and he is in the suit with them currently. AMY GOODMAN: When we come back from our break, we'll find out more about the circumstances of when he was put into jail. Our guest, Barbara Ferguson, who lost her brother in the New York City jail system—the New York State jail system. Dr. Bobby Cohen, who is the federal court appointed doctor who monitors health care in the prisons, and Paul Von Zeilbauer, who is the reporter for The New York Tunes that did this series for The New York Times called "Harsh Treatment." [break] AMY GOODMAN: We're talking about "Harsh Medicine." It's a series of exposes in The New York Times this week by Paul von Zeilbauer about the Prison Health Service, which is P.H.S., a for-profit prison health care industry in this country. And we're looking at some of the cases he exposed this week. We're also joined by Bobby Cohen, who is the federal monitor for prisons, as well as Barbara Ferguson, who has been telling us the story of her brother, Brian Tetrault, who died in his jail cell. I'm Amy Goodman here with Juan Gonzalez. JUAN GONZALEZ: Paul, let's continue with the Brian Tetrault case. Again, how did you get on this particular case? He was a former nuclear scientist who had struggled with Parkinson's disease and was in jail on a minor charge. PAUL VON ZEILBAUER: How I got onto that— f. Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 4 of 8 JUAN GONZALEZ: And also, then, what you discovered about his case. PAUL VON ZEILBAUER: As I mentioned to you, after I began looking at the—after the company's record became an issue and became relevant, I went to the State Commission of Correction. It's a small agency in New York State. Its members are appointed by the Governor, and its mission is to enforce standards in the New York City jails—sorry, in the jails and prisons in New York State. It actually—this Commission began as or got its current mandate after the Attica riots, I believe, in 1971, to prevent that very thing from happening again and to make sure there were humane levels of care and so forth in the jails and prisons. So, what the Commission does is investigate every jail death that occurs, whether it's in a, you know, Broome County jail or whether it's in Attica or another state prison. So, they publish these reports. The reports are public. I filed a Freedom of Information Act request for every report that the Commission had done that mentioned or included or referred to Prison Health Services, because like I said, the company had become a focus of my reporting. So, Mr. Tetrault's case became—was one of those reports. In fact, it's interesting, you know, there were many reports that I received. Some were more interesting than others. And Mr. Tetrault's case was interesting because he had died in 2001, but the Commission Of Correction only became aware of his death in 2003, by mistake, really. One of their employees read a newspaper article upstate that explained one of his family members had filed a lawsuit over the death, which was news to the Commission. And so they began looking into it and found, you know, this case. AMY GOODMAN: So in that particular case, the correctional authorities had not reported the death to the Commission? PAUL VON ZEILBAUER: Yeah. It was the Schenectady County Jail where Brian Tetrault was incarcerated. And the law in New York says that every time you have a death of an inmate, every time an inmate dies or is injured, you have to—excuse Me— AMY GOODMAN: Turn off your watch? PAUL VON ZEILBAUER: Yeah, turn off your watch and then report it to—no, you have to report it to the State Commission, so that there is no excuse for not having a public inquiry. But in this case, Brian Tetrault was released—was supposedly released from jail, even though he was in the hospital bed by the time he died. He was released by the sheriff's office ten minutes before, supposedly ten minutes before he expired. AMY GOODMAN: I want to just read those first two paragraphs of your piece, "Private Health Care in Jails Can Be a Death Sentence.""Brian Tetrault was 44 when he was led into a dim county jail cell upstate New York in 2001, charged with taking some skis and other items from his ex-wife's home. A former nuclear scientist, who'd struggled with Parkinson's, he began to die almost immediately, and state investigators would later discover why. The jail's Medical Director had cut off all but a few of the 32 pills he needed each day to quell his tremors. Over the next ten days, Mr. Tetrault slid into a stupor, soaked in his own sweat and urine, but he never saw a jail doctor again, and the nurses dismissed him as a faker. After his heart finally stopped, investigators said corrections officers at the Schenectady jail doctored records to make it appear he had been released before he died." Dr. Bobby Cohen, how did this happen? DR. BOBBY COHEN: Well, I think that the problem in medical care in prisons is that for a variety of reasons—and this is a general issue, not specifically on what Paul wrote—is that medical care operates within prisons and tends to see its role as 1 Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 5 of 8 supporting its client, which is the system, which is the jail, which is the city, which is the state, rather than the patient. Now, that's not always the case. There are dedicated people, and you know, Paul's article talked about people who had really tried to do a good job. But the nature of incarceration creates a very, very difficult situation in which to provide medical care. It's possible, but difficult. And it is deforming to medical staff just as it's deforming to prisoners and to correctional officers to be in these institutions, but it's hard to understand how nurses could ignore a situation that was just described right now, or how doctors could ignore a situation that—like that, which was described. That is incredibly disturbing, and it happens. It's not the usual, but it happens. It happens often enough. I think that the task is to—in terms of providing medical care in prisons—is to instill and inspire medical staff to understand that their job is difficult, and it can only be done in opposition, actually, to the prison. You cannot provide medical care in a prison, if you go along with the prison rules. You have to complain when patients are not seen. You have to complain when transportation doesn't bring the patient to the specialist. You have to complain when medications are not delivered. Now, I think it is particularly hard for for-profit companies to do that, because they need to have their contract renewed by the facility or the state or the county, and they want to be on good terms with them and not make their job of corrections more difficult. JUAN GONZALEZ: Well, but Paul, I'd like to ask you, I remember years ago, I covered quite a bit of what was going on in the city jails at The Daily News, and I would often get calls from doctors or medical staff who worked on Rikers Island. At that time it was Montefiore Medical Center which had the contract. It was a non- profit voluntary hospital in New York to handle the situation and to deal—provide medical treatment to Rikers. But there would be doctors and nurses who were definitely concerned about what was going on and the kind of treatment that they were being forced to deliver. What has been, from what you can tell, the impact of this move toward more for-profit operations moving into these jails? PAUL VON ZEILBAUER: Well, in the—I can speak in the context of what I have learned through my reporting, and what I understand is that privatization of—if you want to call it private, I mean, it's a public company, Prison Health Services, so "private" is a bit of a misnomer, but it seems as if the difference between a for-profit company providing jail or prison health care and a teaching hospital or a public hospital doing it is that the staffs—the staffs, the clinical staff seems to be smaller. I mean, that just seems—not just in New York City that it occurred, but it's what I found everywhere. AMY GOODMAN: You used the term "skeletal." PAUL VON ZEILBAUER: Yes, the doctors used that term. In fact, I think it was the first article of the three here quoted a doctor who had just resigned in Alabama. She was one of, I think, two doctors in the prison, the state prison in Alabama for about 2,200 inmates who had complained about absolute skeletal staff. This is—I mean, the reason we used it not because it was an aberration or a nice word it use to play gotcha, but it really reflected what I had heard from medical clinicians and medical people who worked for this company in many places. AMY GOODMAN: A second story in your piece. You say, "Two months later, after Mr. Tetrault died, Victoria William Smith, mother of a teenage boy was booked into another upstate jail in Duchess County, charged with smuggling drugs to her husband in prison. She, too, had only ten days to live after she began complaining of chest pains. She phoned friends in desperation. The medical director would not prescribe anything more potent than Ben Gay or the arthritis medicine she had brought with her, investigators said. A nurse scorned her pleas to be hospitalized as a ploy to get drugs. When at last an ambulance was called, Ms. Smith was on the t , Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 6 of 8 floor of her cell shaking from a heart attack that would kill her within an hour. She was 35." Now, Dr. Bobby Cohen, you're the Federal Court appointed doctor who monitors health care in prisons and jails in Michigan, Ohio, Connecticut, New York. Where does P.H.S. fit into this? Prison Health Services. How does it compare to non- profits that run the system. We're sorry they couldn't be us with, but is this a serious crisis in this country, and should they have their contracts pulled? DR. BOBBY COHEN: I have not had a chance to review all of the data that Paul looked at, although I have no reason to believe that he did not carefully review it and that it reflects the reality. Certainly, New York City should have thought very carefully about renewing it at that time, and there should have been a process which allowed this information to get out. I think that in general, the trend towards for- profit health care in the United States is a serious problem, that just as in other health care in the United States, when you put profit into the situation, you get that profit significantly by denying care. And when a company like P.H.S. or other for- profit companies go into a system, the first thing they establish is a utilization review system, which all of your viewers are familiar with from their own encounters with medical care. Utilization review is a really a process of denying access to specialty care. That's in a contract where there's a fixed amount of money, and whatever they don't spend, they keep. That's a very easy way and effective way to make money. That was not the case on Rikers Island right now, because the previous contractor had had a risk contract where they made millions and millions of dollars, tens of millions of dollars by denying care on Rikers island. Actually, they were kicked out because of the serious morbidity and mortality, many, many deaths that occurred during the St. Barnibace reign. I think that there is no room for for- profit health care in prisons, because of the kinds of situation that Paul has described. The process, when a company goes in, and then it gets its contract renewed after two or three years, it essentially has to underbid itself because there are other for-profits who are willing to come in and take the care, so it doesn't ask for increases in fees. When I monitored the Philadelphia jails a number of years ago when P.H.S. was running it, I encouraged them to ask for additional funds when they were renewing the contract, because they had new problems. They had to take ca-e of HIV infection. They had to fix what was not being done. And they were. extremely reluctant to do that, because they knew that they would lose their contract. And so this—the process of competition among for-profits drives the amount of funds available to prisoners down. And that's a serious problem. JUAN GONZALEZ: Doesn't ultimately the problem reside in the fact that, because we are dealing with an inmate population or prisoner population that the local governments, the state governments basically don't care, and want to spend as little money as possible in maintaining the health of these inmates, and there is no constituency—organized constituency to insist on better health care? DR.. BOBBY COHEN: I think that's absolutely right, and it actually is the law in this country. I mean, there are two legal issues. One, in the United States, prisoners are actually entitled to health care which is not deliberately indifferent to their serious needs. The Supreme Court ruled that in 1976, and that's why all of the lawsuits have been filed, and actually, P.H.S. exists because of these lawsuits, because they said, "We can fix it," when the courts told the states or the cities that you are providing unconstitutional care. But there's another legal issue here, which is that the cities and states cannot say it's P.H.S.'s fault. They are responsible. And they have to monitor it. As Paul points out in the article, previously, New York City's Board of Correction, which developed standards for care of medical and mental health in the jails, had a death review board, which reviewed every death, and that process has not been continuing of late. More of that is needed. More involvement of--you know, I really think the more non--the more people who come into prisons and see what's going on, the more people looking the better, because these are E . Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 7 of 8 deforming, terrible institutions that need as much fresh air as possible. AMY GOODMAN: Tell us about the Philadelphia case that you're quoted in the article, Dr. Robert Cohen, about women who were pregnant in the Philadelphia jails. Again, this Prison Health Services provides service in this case. "In Philadelphia in 1999, federal court monitors report warned the company's failure to segregate prisoners who were suffering from T.B. posed a public health emergency. Pregnant inmates, it said, were not routinely tested or counseled for HIV, endangering their babies. In fact, the women were encouraged to refuse pelvic exams." DR. BOBBY COHEN: I believe that I was the state monitor at that time. There's another doctor, Robert Greifinger, who was the federal monitor at that time. My experience in Philadelphia, in terms of care for women in prison, was that there was a process in which women were encouraged to refuse pap tests and pelvic examinations. I would look at the charts and they would say, "refuse, refuse, refuse, refuse, refuse."And then I would ask people, and they told me why, that there were—when supposedly these exams had taken place and they were tested for chlamydia or gonorrhea, common illnesses among women who were in prison, the rates were unbelievably low to zero when we know that the rates of these are very, very high in this population. Additionally, while I was there, while I was reviewing it, two women delivered in their cells who were pregnant. That's—there's—of course, these things happen; but it's usually a story in The Daily News, when someone , delivers in a cab. This does not have to happen in a setting with medical care present. JUAN GONZALEZ: Paul, I'd like to ask you, who runs P.H.S.? Who are the—I mean, there are obviously individuals behind these companies. Is it part of a larger corporation, and how did it develop? PAUL VON ZEILBAUER: Yeah, well, Prison Health Services was founded in 1978, not coincidentally, I believe, two years after the Supreme Court ruling that Dr. Cohen mentioned that required adequate medical care to be provided.to all.inmates. So, you know, there was an opportunity there, because governments.weren't.___.. . interested in it, and in providing it necessarily. I mean, they had to, but they weren't eager to. Companies like Prison Health evolved, and currently the company—make sure I get this right, Prison Health Services is a—there's a holding company that basically owns Prison Health Services. The holding company is called America Service Group. Its stock ticker is A.S.G.R. It's based in Tennessee. Under the America Service Group umbrella, there is Prison Health Services, and there is a pharmacy operation called Secure Pharmacy Plus, which, you know, is a complementary business because the pharmacy provides the medicines to the jails and prisons where P.H.S., Prison Health Services has contracts. So, it—you know, the--it's a public corporation. You can go on the S.E.C. website or anywhere else—or your Ameritrade account, for that matter, and look up the company's performance and who owns it. It's a regular public company. AMY GOODMAN: Just ending with Barbara Ferguson. What are you calling for right now in the death of your brother? BARBARA FERGUSON: At this point, my family, meaning myself and my parents, we are not doing any legal action. My nephew is doing that. He, I believe, and Paul, you can verify this, because you probably have more information. They are trying to settle a suit, I believe, with Prison Health Services. But what we really, really want is that, to go along with Paul, to help these people be aware. PAUL VON ZEILBAUER: This, I mean, as Dr. Cohen mentioned, it's just—you know when you go into jails and prisons, it's by almost necessity, but certainly, there is Democracy Now! I Harsh Medicine: New York Times Exposes How Private Health Care ... Page 8 of 8 riot a lot of sunlight shed on these institutions. AMY GOODMAN: Well, thank you for doing some of that with your series, "Harsh Medicine." I want to thank you, Paul von Zeilbauer for joining us, reporter for The New York Times, wrote the series in the paper. PAUL VON ZEILBAUER: Sure. AMY GOODMAN: Dr. Robert Cohen, federal court-appointed doctor, who monitors health care in prisons and jails, and Barbara Ferguson, sister of Brian Tetrault, who is the prisoner with Parkinson's who, denied proper medical care, died behind bars. The original content of this program is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License. Please attribute legal copies of this work to democracynow.org. Some of the work(s) that this program incorporates, however, may be separately licensed. For further information or additional permissions, contact us. Department of Economics, UCSB Departmental Working Papers (University of California, Santa Barbara) Year 2007 Paper 1"07 X07 Prison Health Care: Is Contracting Out Healthy? Kelly Bedard * Ted E. Prech t "University of California, Santa Barbara tUniversity of California,Santa Barbara This paper is posted at the eScholarship Repository,University of California. http://repositories.cdlib.org/ucsbecon/dv,rp/11-07 Copyright©2007 by the authors. Prison Health Care: Is Contracting Out Healthy? Abstract U.S Prison health care has recently been in the news and in the courts. A particular issue is whether prisons should contract out for health care. Con- tracting out has been growing over the past few decades. The stated motivation for this change ranges from a desire to improve the prison health care system, sometimes in response to a court mandate, to a desire to reduce costs. This study is a first attempt to quantify the impact of this change on inmate health. As morbidity measures are not readily obtainable, we focus on mortality. More specifically, we use a panel of state prisons from 1979-1990 and a fixed effects Poisson:model to estimate the change in mortality associated with increases in the percentage of medical personnel employed under contract. In contrast to the first stated aim of contracting, we find that a 20 percent increase in percentage of medical personnel employed under contract increases mortality by 2 percent. Prison Health Care: Is Contracting Out Healthy? Kelly Bedard H.E. Frech III Department of Economics Department of Economics University of California, Santa Barbara University of California, Santa Barbara kelly(r0,econ.ucsb.edu frech a,econ..ucsb.edu September 2007 Abstract U.S. Prison health care has recently been in the news and in the courts. A particular issue is whether prisons should contract out for health care. Contracting out has been growing over the past few decades. The stated motivation for this change ranges from a desire to improve the prison health care system, sometimes in response to a court mandate, to a desire to reduce costs. This study is a first attempt to quantify the impact of this change on inmate health. As morbidity measures are not readily obtainable, we focus on mortality. More specifically, we use a panel of state prisons from 1979-1990 and a fixed effects Poisson model to estimate the change in mortality associated with increases in the percentage of medical personnel employed under contract. In contrast to the first stated aim of contracting, we find that a 20 percent increase in percentage of medical personnel employed under contract increases mortality by 2 percent. Thanks are due to Mary Alice Conroy, Ph.D.,Director of Graduate Studies in Forensic Psychology, Sam Houston State University and Clifford Leonard, Ph.D. Staff Psychologist, Pelican Bay State Prison, California, for helpful discussions and background in prison health care. An earlier version of this paper was presented at the International Health Economics Association meetings in Copenhagen, July 9,2007. Thanks are due to participants there, especially Avi Dor. Keywords: prison health care, contracts,managed care, outcomes, mortality JEL Numbers: I12, I18, K23,L14, L23 1. Introduction There has been a large increase in contracting out for health care in U.S. prisons. As of 2004, 32 states contract for some or all prison health services(LaFaive 2006). Despite the massive shift towards contracting out for prison health care, the popular press has voiced concerns about the resulting quality of service for inmates. For example, a recent series of New York Times articles by Paul von Zielbauer(2005A, B, Q blames contracting out for poor health care in New York and Alabama, including inmate suicides and prisoners dying after being denied treatment. He blames these poor outcomes on Prison Health Services (PHS), a large health care company which has recently received large contracts in the states he studies. In fact,PHS is the largest private healthcare provider for penal institutions (both prisons and jails),providing care in 28 states for 237,000 inmates, about 10 percent of the penal population, grossing$690 million in 2004 (Zeilbaurer 2005A).1 While this is a big company, the market for outsourced medical care is much larger still. The president of PHS estimates that$3 billion of the $7 billion spent on penal medical care is contracted out(Business Week 2005). While there are concerns that prison health care contracting out leads to understaffing and under-treatment(Robbins 1999), it is also possible that outsourcing produces efficiency gains by applying the principles of managed health care and thereby reduces costs without reducing quality. In fact, contracting out has sometimes been instituted in response to court orders as a means of improving prison health care quality (McDonald 1999). The argument for outsourcing as a means to improve quality rests on ' State and federal prisons house individuals who have been sentenced as punishment for crimes. Jails, typically operated by local governments,largely house individuals who have been accused of crimes. Jail stays,on average,are for shorter periods. While many economic and legal issues are the same for jails and prisons,our data is limited to prisons. 2 the notion that independent organizations (often, but not necessarily profit-seeking firms) are more flexible and efficient than governmentally operated prison health care staffs. For one thing, contract health care providers are allowed to pay professionals wages that exceed state-mandated pay schedules that are often too low for difficult work in prisons in isolated areas (Gater 2005).2 Profit-seeking firms also have better incentives to produce care more efficiently because managers are allowed to keep the residual earned by reducing costs (Alchian and Demsetz 1972, Boardman and Vining 1989, Frech 1976, Fizel and Nunnikhoven 1992). While there is a substantial literature examining the relative efficiency of government versus private firms in the context of goods produced directly for markets, such as insurance or privatization of state-owned enterprises (Ehrlich, Gallais-Hamonno, Lieu, 1994,Boardman and Vining 1989, Frech 1976, Shleifer 1998,), to the best of our knowledge only Hart, Shleifer and Vishny(1997) formally models contracting for services that are not bought on the open market. They set up a simple model where the - provider, either a government employee or a private contracting firm can invest in either improving quality(which also tends to raise price) or reducing cost(which also tends to reduce quality). They show that private contractors have stronger incentives to both improve quality and reduce costs than government employees. The problem is that private contractors may have incentives that are too strong to reduce costs, since they ignore the adverse impact on quality. They apply the model to the question of privatizing entire prisons. Like contracting out for prison health care,privatizing entire prisons is growing in popularity in the U.S., though it is much less common than contracting out 2 All these issues were raised by Judge Thelton Henderson in appointing a receiver to take over the California system(Plata v.Schwartznegger 2005). 3 health care alone.3 Their model suggests that prisons are not good candidates for privatization because of the possibility for significant reductions in quality as a byproduct of reducing costs. And, of course, inmates are not effective monitors of quality. Consistent with this prediction, they present limited evidence that private prisons have both lower costs and lower quality. Given the theoretically ambiguous impact of prison health care contracting out on the quality of inmate health care, the objective of this study is to quantify the impact. Ideally, we would include measures of morbidity and mortality. Unfortunately, morbidity data is not readily available. As such, we focus on mortality. In particular, we use Census of Prison data from 1979-1990 and a fixed effects Poisson model to estimate the impact of increases in health care outsourcing on inmate mortality. We find a negative effect of contracting out on health(a positive effect on death). More specifically, we find that a 20 percent increase in percentage of medical personnel employed under contract increases mortality by 2 percent. 2. Prison Health Care Contracting 2.1. The Ilistory ojrCourt Involvement Before the federal courts began intervening, health care in American prisons was poor and limited. Prison officials often considered medical care as a privilege, rather than a right. It was sometimes withheld to discipline inmates. Care was often dispensed by retired military corpsmen and untrained inmate nurses. The few physicians that existed often had restricted institutional licenses(McDonald 1999, Anno 2004). The early descriptive literature:is harrowing. For example, Pennsylvania inmates who tried to hang 3 In 1995,private prisons had only about 3 percent of the market(Hart,Shleifer and Vishny 1998). 4 themselves were simply cut down, medicated and returned to their cells without psychological evaluation(McDonald 1999,Anno 2004). One of the complaints of the rioters in the infamous 1971 Attica New York prison riot was inadequate health care. Although prisoners and prisoner advocates sued prisons on the grounds that health care was inadequate, during this early period the courts generally took a hands-off approach. The legal environment changed abruptly when the federal courts began to view health care through the lens of the U.S. Constitution's Eighth Amendment prohibition of cruel and unusual punishment. An early landmark case in this regard was the federal district court decision, affirmed by the Fifth Circuit of Appeals,Newman v. State of Alabama (1974). Among the factual findings of the decision was the story of a quadriplegic who was not given intravenous feeding in the three days before his death. The court found the conditions barbarous and in violation of the Eighth Amendment. In 1976, the Supreme Court addressed these issues in Estelle v. Gamble. They declared that"deliberate indifference"to a prisoner's serious medical problem is a Constitutional violation. Subsequent rulings further established the right to "reasonably adequate medical care"(McDonald 1999). Partly due to the vagueness of these standards,4 these legal changes initiated an endless stream of court cases and led to heavy involvement of the courts in forcing improvements in prison health care. Medical care is the most litigated issue involving prisons (Schlanger 2003). By 1996, 36 states were under federal court order to improve prisons. The majority of these cases included health care (McDonald 1999). A survey of °Most observers cite under-treatment,especially of relatively sick prisoners. But,the concept of "reasonably adequate medical care"is so vague that surprising outcomes of any kind can occur. For example,in a controversial instance,the California prison system provided a heart transplant to twice convicted of armed robber,at a cost of$1,000,000(McKneally and Sade 2003). 5 prisons in 2003 showed that 56 percent were operating under court orders regarding medical care and 65 percent had been under court orders that had been lifted by 2003. In the new legal situation created by the federal decisions, various professional organizations stepped in to set standards. Meeting these standards supports a legal defense of following the usual practice. Free entry into standard setting led to as many as four separate sets of standards. Today, there are still two, those of the American Correctional Association and the National Commission on Correctional Health Care. There are also generally higher standards that are not specific to prisons that some prisons do meet. 2.2. Prison Health Care Costs and Health Status Naturally, in this setting, costs for prison health care have risen substantially. Although data are surprisingly difficult to come by, surveys indicate that spending in 1995 was about$2,308 per prisoner per year. That was up from $880 in 1982, an increase of 160 percent(McDonald 1999). The variation in spending across state prison populations is also striking. In 1.998,costs ranged from a low of$1,001 in Alabama to a high of$4,365 in Massachusetts (Lamb-Mechanick and Nelson, undated). Note that per capita health care spending in the U.S. as a whole in 1995 was $3,509(U.S. Census 1997). The seemingly high level of prison health care spending described above underlies public policy towards cost control, including contracting out. But, one should be careful making comparisons between inmate and non-inmate medical expenditures. While prisoners are quite young, they are generally thought to be less healthy than the population at large and therefore to need more medical services. However, the evidence 6 for this is mixed. For example, death rates in prisons are lower than for the general population, after controlling for race, sex and age, though they are higher for infectious disease and suicide (McDonald 1999). In a study of the Cook County(Chicago)Jail, Kim et al(2006) found a 68 percent lower adjusted mortality rate for inmates than for the general population. On the other hand, when prisoners are released,their death rates jump and become much higher than those of the general population. In a study of former Washington State inmates, the adjusted death rate for the former inmates was 3.5 times the state's overall death rate (Binswanger et al 2007). We know of only one nationwide analysis of prison health care costs, done by Lamb-Mechanick and Nelson (undated). They use state level data obtained from a dedicated survey of state departments of corrections,plus the Federal Bureau of Prisons (BOP) in 1998. Lamb-Mechanick and Nelson report per day health care costs per inmate ranging from$2.74 in Alabama to $11.96 in Massachusetts, with a mean of$7.15. They also study the determinants of costs using a simple OLS model and data from-38 states. -The regressors include several measures of medical professional inputs, and whether juveniles are included in the budget. No state socio-economic variables are used. For our purposes, the most interesting finding involves the dummy variable for whether the state used capitated contracts (like many private sector HMOs) for ambulatory care. 18 states report using such contracts. Lamb-Mechanick and Nelson find that states with capitated contracts have 31 percent lower costs per inmate. While this result is interesting, it is reasonable to be quite concerned about omitted variables bias in this context and one should therefore interpret these estimates with care. 7 One rationale for both contracting out and using private-sector managed care techniques is to reduce costs. Another technique borrowed from the private sector(and from Medicare) is prisoner copayments. This has been shown by Hyde and Brumfield (2003) to be effective. They examine the initiation of small copayments ($3.00 for a sick care visit and$2.00 for a prescription)in Idaho prisons in 1998.5 As one might expect, the number of sick care requests declined by about 40 percent. This result is roughly consistent with, though slightly larger than, the classic RAND study comparing free care to small copayments (Newhouse et al 1981 and 1993). However, the comparison is not perfect as there is likely to be significant non-price rationing in prisons, especially in the absence of copayments. 2.3. Prison Health Care Quality and Outcomes Our knowledge about the impact of contracting out on the quality of prison health care is limited to case studies from Texas, Baltimore and Salt Lake City. As a result of successful inmate lawsuits in the early 1990s, the U.S. District Court ordered Texas to improve prison health care. In 1994, Texas responded by contracting out to a managed care network established by and integrated with Texas state medical schools and their affiliated teaching hospitals. The system uses a global capitation system, an HMO-like system with strong incentives for cost control. Rainier and Stobo (2004) state that the result has been improved health care by many process measures. For example, staff vacancies declined greatly and compliance with practice guidelines improved. More interestingly, several outcome measures also improved, including blood sugar levels in diabetics,the proportion of inmates with high blood pressure, and death rates from AIDS 5 Indigent inmates(about 20 percent of inmates)do not have to pay these fees. 8 and asthma. At the same time, this contracting out strategy saved the state $215 million over six years. In a similar vein, as a result of prisoner protests in the Baltimore City Jail, health care was contracted out to a newly created nonprofit organization in 1977. A comparison of outcome measures pre and post contracting shows substantial effects. While the number of sick visits fell from 62.9 to 27.4 patients per day per 1,000 inmates, the length of time nurses spent with patients per visit rose from 2.8 to 10.9 minutes. At the same time,clinical staffing at the jail increased by 60 percent while costs rose by only 13 percent, largely because hospital use declined. Overall,Freeman(198 1) considers this to be a substantial improvement in care. Lastly, Szykula and Jackson(2005) detail a case study for managed mental health techniques in a large Salt Lake City jail. They report lower costs and much lower levels of psychotropic medication of the inmates after the initiation of manage care. 3. Inmate Mortality Data We construct a balanced three year panel from the 1979 and 1984 Census of State Adult Correction Facilities and the 1990 Census of State and Federal Adult Correction Facilities. The sample is restricted to these three years because they are the only surveys that include the necessary data. Because federal data are only reported in 1990, the panel is also restricted to state prisons. All data are self reported at the institution level. As the objective is to estimate the impact of medical contracting on inmate mortality, we restrict the sample to facilities that are likely to offer at least some amount of medical care. Operationally this means that the sample is restricted to state prisons housing adults with 9 a minimum capacity of 100 inmates and a positive number of professional staff in each of the three years. This restriction reduces the sample from 1560 to 1095 prisons. Most of the excluded prisons are very small and have no medical staff. We use two dependent variables: deaths due to illness (including AIDS) and deaths due to illness or suicide. Deaths due to violence are excluded. Our primary independent variable is the percentage of professional staff under contract(not on regular payroll). The number of professional staff is the number of medical doctors, dentists, nurse,paramedics,psychiatrists,psychologists, educational and vocational counselors, teachers, social workers, and so on. We are forced to amalgamate medical and other professionals because the 1990 data does not separately identify them. Section 4.1 examines the possible biases introduced by this amalgamation. In particular, we use the more detailed data available in the 1979 and 1984 data to approximately bound the estimates. Table 1 reports the average percentage of professional staff employed under contract at the prison level. Columns 1 -and 2 show that the fraction of professional staff - employed under contract was essentially stable between 1979 and 1984, and then increased substantially between 1984 and 1990. The remaining control variables, other than the prison fixed effects, are listed in Table 2. All models include the number of professional staff, the number of other staff, prison population,prison capacity, prison security level, and the number of inmates killed in the past year. The number of inmates killed is a proxy for social conditions in the prison. The columns in Table 2 report these summary statistics for a variety of sub- samples. Our primary sample includes all prisons with a minimum capacity of 100 inmates and a positive number of professional staff in each of the three years. Column 2 10 restricts the sample to prisons with a hospital, a shared hospital, or an infirmary and column 3 restricts the sample to just prisons with a hospital. Columns 4 and 5 restrict the sample to prisons with an average capacity of 500+and 1000+, respectively. We use these samples in Section 4 to check the sensitivity of the results to various sample specifications. 4. Fixed Effects Poisson Model The objective is to estimate the impact of medical contracting in prisons on inmate mortality: M;, =a; +0; +l3Cu +yP,.; +X;;B+E;; (1) where i denotes prisons,t=1979, 1984, or 1990,M is the annual prison-level mortality count, a is a vector of prison fixed effects, 0 is a vector of year indicators, C is the proportion of professional staff employed on contract(ranges from 0 to 1),P is the number of professional staff,Xis a vector of time-varying prison characteristics, and E is the usual error term. The central feature of our prison mortality data is that it is a non- negative count with a large number of zeros(see Table 3 and Figure 1). As such,we estimate equation(1)using a fixed effects Poisson model. We also report OLS estimates for comparison. The estimates for equation(1)are reported in Table 4. Columns 1 and 2 report the fixed effects Poisson estimates when mortality includes both illnesses and suicides and excludes suicides,respectively. For comparative purposes, columns 3 and 4 report the same estimates for a linear fixed effects model. All models are weighted by average capacity. The sample sizes are smaller for the Poisson models compared to the OLS 11 models because prisons with constant mortality counts are dropped in the fixed effects Poisson estimation. The first row reports the primary coefficient of interest,f3, which is the impact of contracting out on inmate mortality. Our preferred estimate includes deaths due to suicide and uses a Poisson model (column 1). Under this specification, the contracting coefficient is 0.352 with a standard error of 0.036.6 This impact is both statistically significant and economically important. The coefficient estimate for contracting out implies that a 20 percent increase in contracting(this is the mean for the biggest change observed by prison) increases mortality by 0.07 deaths or 2 percent relative to a mean death count of 3.49. Alternatively, one can think about a complete change from no contracting out to complete contracting out. In this case, the estimated coefficient estimate implies that mortality will rise by 0.352, or 10 percent. However, one should be careful with this interpretation since there are very few changes of such magnitude in the data. The point estimates for the other three specifications are similar in magnitude. The other coefficients are reported in the remaining rows of Table 4. Focusing on column 1, as one might expect,mortality falls as professional staff increases. On the other hand, increases in non-professional staff and prison population are associated with increases in inmate mortality. Also as expected,the trend in prison mortality is upward. Table 5 replicates columns 1 through 4 in Table 4 under a variety of sample specifications. For comparative purposes the first row reports the baseline estimates. The second row restricts the sample to prisons with a hospital, shared hospital, or an infirmary. Row 3 restricts the sample to prisons with a hospital. Rows 4 and 5 use prison 6 Two related notes. One,the standard errors are quite a bit smaller in the Poisson regressions than the OLS regression. This makes sense,since this is count data. Two,the fixed effects are jointly significant in all models,as one would expect with such heterogeneous institutions as prisons. 12 capacity, 500+inmates and 1000+inmates, as an alternative to direct measurement of medical facilities, to focus on prisons that are more likely to provide a high proportion of medical services in the prison itself. While the point estimates for large prisons and prisons with a hospital are substantially larger than the baseline and the other two less restrictive sub-samples, they are similar in percentage terms. A 20 percent increase in contracting increases mortality by 0.13 deaths or 2 percent relative to a mean death count of 5.75 for prisons with a hospital and by 0.13 deaths or 2 percent relative to a mean death count of 5.23 for prisons with 1000+inmates. 4.1. Medical Staff Measitrement Problems For our purposes, the primary flaw of available data is the fact that medical staff is not separately identified from other professional staff in the 1990 survey. As a result,we are forced to use all professional staff and the percentage of them employed under contract instead of isolating medical contracting out. This lack of disaggregated data is - unfortunate since most of the substantial changes in contracting occur between 1984 and 1990. The 1979 and 1984 surveys do separate medical personnel from other professional staff. Table 6 therefore replicates Table 4 with three differences. First, the sample only includes the first two years, 1979 and 1984. Second, medical staff and other professional staff enter all models separately(rows 1 and 3)as do the percentage of medical and other professionals who are under contract(rows 2 and 4). Third, the sample is restricted to prisons with at least some professional and medical staff in both 1979 and 1984. Several features of Table 6 warrant comment. First, the point estimates are less consistent across specifications. This is likely due to the limited number of prison 13 contracting changes between 1979 and 1984. Second, in this sample period, the prisons not dropped from the Poisson model are generally large prisons; since these are the only institutions with contracting and/or death count changes. As such, it may not be surprising that the OLS and Poisson estimates are quite different, with the Poisson estimates being similar to the large institution estimates reported in Table 5 and the OLS estimates being more similar to the baseline estimates reported in Table 4. Third,while the point estimates for the percentage of medical staff contracted out are estimated reasonably precisely, the estimates for the other medical and professional measures are very noisy. Again this likely reflects the fact there are very few changes between 1979 and 1984. Finally, although not reported in the table,the average percentage of contracting is similar across medical and other professional categories, and changes very little between years. In 1979 9.5 percent of medical staff are employed under contract compared to 8.3 percent for other professionals. By 1988 these percentages had changed slightly to 8.8 percent for medical staff and 8.0 for other professionals. Taken as a whole these finding suggest that proxying medical contracting with professional contracting is likely to be fairly reliable. 4.2. Endogenous Medical Contracting The analysis of the impact of medical contracting on prisoner mortality raises the question of endogeneity. More concretely, one may be concerned that the results partly reflect the decision of prisons with high and rising death rates to switch towards medical 14 contracting to slow the rise in the death rate.7 As we have three years of data, we can investigate this possibility by relating changes in mortality in the earlier period to contracting out choices in the later period. We estimate the following simple model: OCi90-84 _a+A4 +)TAM t 84-79 +YPt84 +Xi84 B+B.i84 (2) where i denotes prisons, A1,90-84 is the change in the percentage of professional workers employed under contract from 1984 to 1990, AMi14-79 is change in prison-level mortality from 1979 to 1984,0 is a 1984 year indicator,P is the member of professional staff,Xis a vector of prison characteristics as measured in 1984. Using equation (2), we ask whether prisons that experienced increases in inmate mortality responded by changing their professional staff contracting rate. The results are reported in columns 1 and 2 in Table 7. Whether mortality includes or excludes suicides, there is no relationship between the change in mortality between 1979 and 1984 and the change in medical contracting between 1984 and 1990. The point estimates are zero to three decimal places and the standard errors are small. In order to check the sensitivity of this finding to alternative specifications, columns 3 through 8 replace the change in mortality with the level of mortality in 1984, 1979, both and 1979 and 1984. The results for all specifications are similar: the data indicate that prisons did not respond to mortality changes by changing the percentage of their medical staff employed under contract, at least during the period of for which we have data. 7 To the extent that higher mortality rates deter crime,as shown Katz,Levitt and Shustorovich(2003),it is also possible that the composition of prisoners is changing over time. While it is not obvious how this would bias the reported estimates,we have no way to deal with possibility of such selection. 15 5. Conclusion We find no evidence to support the positive rhetoric regarding the impact of prison health care contracting out on inmate health, at least as measured by mortality. Our findings of higher inmate mortality rates under contracting out are more consistent with recent editorials raising concerns about this method of delivering health care to inmates. In fact, the reported results lead one to wonder if Paul von Zielbauer(2005A, B, C) is indeed correct asserting that contracting out may be as good as "death sentence,"for at least some inmates? It is, of course possible that the estimated declines in health care quality are offset by gains in lower costs. The literature (Lamb-Mechanick and Nelson, undated) shows that contracting out does reduce costs. 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"Inmate Litigation: Results of a National Survey,"LJN Exchange, Lonogmont, CO: National Institute of Corrections Information Center. 18 Shleifer,Andrei, 1998, "State versus Private Ownership,"Journal of Economic Perspectives 12(4) (Autumn): 133-50. Szykula, Steven A. and Dawn F. Jackson, 2005. "Managed Mental Health Care in Large Jails: Empirical Outcomes on Cost and Quality,"Journal of Correctonal Health Care 11 (3): 223-240. Von Zielbauer, Paul, 2005A"As Health Care in Jails Goes Private, 10 Days Can Be a Death Sentence,"New York Times, (Feb. 27). Von Zielbauer, Paul, 2005B. "In City's Jails, Missed Signals Open Way to Season of Suicides,"New York Times, (Feb. 28). Von Zielbauer, Paul, 2005C. "A Company's Troubled Answer for Prisoners With H.I.V."New York Times, (Aug. 1). U.S. Bureau of the Census, 1997, Statistical Abstract of the United States: 1997(117th Ed.) Washington, D.C. 19 year==79 year--=84 1 .75 .5 c .25 M 1 CL 0 5 10 15 O year-=90 c O 1 U ca Li .75 .5 25 "s 1 0 0 5 10 15 Number of Deaths Figure 1. Annual Prison-Level Inmate Death Count Table 1. Contracting Percentage (Measured at the Prison Level) 1979 1984 1990 None 53 59 31 1-24 percent 27 24 41 25-49 percent 15 11 15 50-74 percent 4 5 7 75+ percent 1 2 7 Unweighted. Table 2. Prison-Level Summary Statistics (1) (2) (3) (4) (5) Deaths due to illness or suicide 3.49 3.63 5.75 4.00 5.23 (6.06) (6.16) (8.88) (6.39) (7.23) Deaths due to illness 3.01 3.13 5.02 3.45 4.51 (5.63) (5.73) (8.35) (5.96) (6.79) Percent contract professional 0.10 0.10 0.12 0.09 0.08 (0.19) (0.18) (0.21) (0.17) (0.16) Professional staff 80.23 82.74 96.11 89.80 109.67 (69.36) (69.83) (89.64) (70.15) (74.45) Other staff(in 100s) 5.45 5.61 5.95 6.07 7.36 (4.64) (4.66) (4.65) (4.66) (4.89) Prison population (in 100s) 15.85 16.38 16.91 17.95 22.76 (13.04) (13.09) (13.37) (12.91) (12.89) Prison capacity(in 100s) 15.97 16.51 16.90 18.09 22.98 (13.20) (13.26) (13.30) (13.08) (13.05) Maximum security facility 0.51 0.53 0.60 0.56 0.61 (0.50) (0.50) (0.49) (0.50) (0.49) Medium security facility 0.41 0.41 0.38 0.41 0.37 (0.49) (0.49) (0.49) (U:49) (0.48) Minimum security facility 0.08 0.07 0.03 0.04 0.02 (0.28) (0.25) (0.16) (0.19) (0.13) Inmates killed per 100 inmates 0.02 0.02 0.03 0.03 0.03 (0.06) (0.06) (0.07) (0.06) (0.05) Average Prison-Level Death Rate Due to illness or suicide (per 1000 Inmates) 2.2 2.2 3.4 2.2 2.3 Due to illness (per 1000 Inmates) 1.9 1.9 3.0 1.9 2.0 Sample size 1095 966 255 615 276 Sample restricted to prisons with: A hospital,shared hospital, or infirmary No Yes No No No A hospital No No Yes No No Average Capacity 500+ No No No Yes No Average Capacity 1000+ No No No No Yes Weighted by average prison capacity. Table 3. Prison-Level Death Counts by Year Death Count 1979 1984 1990 0 251 202 163 1 52 69 67 2 20 37 36 3 8 13 24 4 17 11 20 5 8 7 9 6 2 5 10 7 1 4 7 8 1 4 3 9 1 5 5 10 2 1 0 11 1 2 2 13 0 1 0 14 0 1 3 15 0 0 2 16 0 1 0 18 0 0 3 19 1 1 1 20 0 0 2 22 0 0 2 26 0 0 1 29 0 1 1 32 0 0 1 38 0 0 2 42 0 0 1 Unweighted. Table 4. The Impact of Contracting Out on Inmate Mortality Poisson OLS: log(1+deaths) (1) (2) (3) (4) Percent contract professional 0.352 0.284 0.307 0.243 (0.036) (0.039) (0.125) (0.127) Professional staff -0.002 -0.001 -0.001 0.000 (0.000) (0.000) (0.001) (0.001) Other staff(/100) 0.017 0.021 0.009 0.016 (0.002) (0.003) (0.010) (0.011) Prison population (/100) 0.018 0.009 0.010 0.001 (0.002) (x.002) (0.008) (0.008) Prison capacity (/100) 0.005 0.007 0.019 0.020 (0.002) (0.002) (0.009) (0.009) Inmates killed (per inmate) 0.484 0.117 0.070 -0.108 (0.094) (0.108) (0.355) (0.359) Medium security facility -0.098 -0.117 -0.094 -0.102 (0.017) (0.018) (0.066) (0.067) Minimum security facility -1.080 -0.993 -0.299 -0.292 (0.053) (0.054) (0.131) (0.133) 1984 0.484 0.488 0.198 0.194 (0.012) (0.013) (0.040) (0.040) 1990 0.969 1.041 0.436 0.428 (0.016) (0.017) (0.056) (0.056) Sample size 750 711 1095 1095 Deaths include suicides Yes No Yes No All models also include prison indicators.Weighted by average prison capacity.Standard errors are in parentheses. OLS standard errors are heteroskedastic consistent.Bold coefficients are statistically significant at the 5%level and bold italics are statistically signif cant at the 10%level. Table 4. Robustness Poisson OLS: log(1+deaths) (1) (2) (3) (4) Sample restricted to prisons with: All priscns 0.352 0.284 0.307 0.243 (0.036) (0.039) (0.125) (0.127) [750] [711] [1095] [1095] Hospital, shared hospital, or infirmary 0.373 0.298 0.345 0.269 (0.037) (0.040) (0.138) (0.140) [684] [654] [966] [966] Hospital 0.659 0.521 0.677 0.472 (0.051) (0.055) (0.250) (0.251) [213] [201] [255] [255] Prison capacity 500+ 0.369 0.294 0.414 0.331 (0.038) (0.041) (0.191) (0.194) [540] [519] [615] [615] Prison capacity 1000+ 0.652 0.522 0.728 0.558 (0.044) (0.047) (0.324) (0.340) [270] [261] [2761 [276] Deaths nclude suicides Yes No Yes No All models include the variables listed in Table 3.Weighted by average prison capacity.Standard error are in parentheses. OLS standard erros are heteroskedastic consistent.Sample sizes are in square brackets.Bold coeffcients are statisticallylevel significant at the 5%and bold italics are statistically significant at the 10%level. Table 6. Separating Medical and Other Professionals Poisson OLS: log(1+deaths) (1) (2) (3) (4) Percent contract medical professionals 0.6754 1.0502 0.3303 0.3731 (0.0668) (0.0838) (0.1620) (0.1567) Medical staff 0.0022 0.0000 0.0024 0.0006 (0.0005) (0.0005) (0.0021) (0.0021) Percent contract non-medical professionals -0.1924 -0.1579 -0.0028 -0.0200 (0.0613) (0.0713) (0.1843) (0.1782) Other professional staff -0.0012 0.0008 -0.0014 0.0006 (0.0004) (0.0005) (0.0015) (0.0014) Other staff(/100) 0.0477 0.0781 0.0923 0.1352 (0.0095) (0.0106) (0.0381) (0.0368) Prison population (/100) 0.0352 0.0249 0.0134 -0.0025 (0.0031) (0.0034) (0.0122) (0.0118) Prison capacity (/100) 0.0241 0,.0173 0.0173 0.0142 (0.0038) (0.0042) (0.0126) (0.0121) Inmates killed (per inmate) -0.5864 -0.8387 -0.2255 -0.1596 (0.1427) (0,1710) (0.4392) (0.4247) Medium security facility -0.3891 -0„4749 -0.1437 -0.1512 (0.0377) (0.0432) (0.0956) (0.0925) Minimum security facility -0.9005 -1.0281 -0.2261 -0.2995 (0.0919) (0.0945) (0.1842) (0.1781) 1984 0.2228 0.2627 0.0827 0.0922 (0.0179) (0.0204) (0.0495) (0.0479) Sample size 370 322 638 638 Deaths include suicides Yes No Yes No All models also include prison indicators.Weighted by average prison capacity.Standard errors are in parentheses. OLS standard errors are heteroskedastic consistent.Bold coefficients are statistically significant at the 5%level and bold italics are statistically significant at the 10%level. Table 7. Change in Professional Contracting between 1984 and 1990 (1) (2) (3) (4) (5) (6) (7) (8) Death Change (1984-1979) 0.000 0.000 (0.008) (0.008) Deaths in 1984 0.007 0.007 0.009 0.015 0.005 0.002 (0.007) (0.007) (0.010) (0.011) (0.008) (0.008) Deaths in 1979 0.006 0.014 (0.011) (0.012) Other controls measured in 1984: Professional staff -0.001 -0.001 -0.001 -0.001 -0.001 -0.001 -0.001 -0.001 (0.001) (0.001) (0.001) (0.001) (0.001) (0.001) (0.001) (0.001) Other staff(/100) 0.004 0.004 0.002 0.002 0.004 0.004 0.003 0.003 (0.016) (0.016) (0.016) (0.016) (0.016) (0.016) (0.016) (0.016) Prison population (/100) 0.012 0.012 0.012 0.012 0.012 0.012 0.012 0.012 (0.010) (0.010) (0.010) (0 010) (0.010) (0.010) (0.010) (0.010) Prison capacity(/100) -0.011 -0.011 -0.012 -0.012 -0.011 -0.011 -0.011 -0.011 (0,009) (0.009) (0.009) (0.009) (0.009) (0.009) (0.009) (0.009) Inmates killed (per inmate) -0.336 -0.336 -0.346 -0.341 -0.381 -0.410 -0.372 -0.405 (0,284) (0.284) (0.282) (0.282) (0.287) (0.286) (0.287) (0.287) Medium security facility -0.002 -0.002 0.003 0.002 0.005 0.006 0.006 0.007 (0.036) (0.036) (0.036) (0.036) (0.037) (0.037) (0.037) (0.037) Minimum security facility 0.030 0.030 0.032 0.031 0.034 0.034 0.034 0.034 (0.047) (0.047) (0.047) (0.047) (0.047) (0.047) (0.047) (0.047) Constant 0.117 0.117 0.118 0.118 0.115 0.116 0.116 0.117 (0.037) (0.037) (0.036) (0.037) (0.037) (0.036) (0.037) (0.037) Sample size 365 365 365 365 365 365 365 365 Deaths include suicides Yes No Yes No Bold coefficients are statistically significant at the 5%level and bold italics are statistically significant at the 10%level. Unweighted. American Civil Liberties Union:ACLU and PJC Urge Maryland... http://www.aclu.org/prison/gen/14742prs20050601 .html BECOME A CARD-CARRYING MEMBER OF THE ACLU: _.. A 61 CAM OVOL Ll JOIN NOW URL:http:/Manu.adu.or<VprisorVgerJ14742prs2005C601.himI ACLU and PJC Urge Maryland Board to Reject Contract with Company Known for Providing Deficient Medical Care in Prisons(6i1/2005) FOR IMMEDIATE RELEASE Contact: media@aclu.org ANNAPOLIS, MD -- Citing Correctional Medical Services' poor record for dispensing medical care to prisoners, the American Civil Liberties Union and Public Justice Center today urged Maryland's Board of Public Works to reject a proposed contract with the for-profit company. "Correctional Medical Services' history of cutting corners to maintain profits jeopardizes the lives of thousands of incarcerated people across the country," said Elizabeth Alexander, Director of the ACLU's National Prison Project. "Many states have already learned a painful lesson from their dealings with Correctional Medical Services. Maryland must avoid handing over the care of its prisoners and jail detainees to a company with a disastrous reputation." Correctional Medical Services (CMS) currently holds contracts in 27 states. In Michigan, where the company provides care to prisoners statewide, CMS has come under heavy scrutiny for its attempts to save money by limiting prisoners' referrals to outside medical specialists. A federal court found that excessive delays in providing prisoners with referrals contributed to three deaths during an 18-month period. Five other prisoners who died during the same time period also experienced significant delays in treatment. Last week, the Maryland Board of Public Works announced that at a meeting today it will review for approval a two-year statewide medical services contract between the state's Department of Public Safety and Correctional Services and CMS. The new contract is scheduled to begin July 1, 2005. Under the new contract, CMS would provide care to more than 4,000 detainees confined at the Baltimore City Detention Center, which has come under fire in recent years for providing deficient medical care. In August 2002, the U.S. Department of Justice cited the jail for 107 violations of health and safety standards. Since 2002, the ,ACLU and Public Justice Center have been involved in litigation about the medical care provided at the Baltimore Jail by the current for-profit medical and mental health care provider, Prison Health Services. Even with the significant rise in spending for the new contract, according to the state's estimates, health services are still under funded by several million dollars. The ACLU and Public Justice Center expressed concern that simply switching for-profit providers without increasing resources to fund treatment and maintaining close contract oversight will leave detainees with the same poor care they received under Prison Health Services. "There is little point in changing company names if the continuation of inadequate funding and indifference from the state regarding detainee health remains the same," said Sally Dworak-Fisher, an attorney with the Public Justice Center. "In an environment without consistent outside oversight and inspection, the motivations of for-profit companies like CMS and Prison Health Services become dangerous. Cutting corners to preserve profits but risk the health and lives of detainees is inexcusable, and Maryland officials are responsible when the care is constitutionally inadequate." Today's hearing before Maryland's Board of Public Works will be held at 10:00 AM in the Governor's Reception Room, 2nd floor of the Annapolis State House. 1 of 2 4/7/08 10:50 PM American Civil Liberties Union:ACLU and PJC Urge Maryland... http://www.aclu.org/prison/gen/l 4742prs20050601.html ©ACLU,125 Broad Street,18th Floor New York,NY 10004 This is the Web siteof the American Civil Liberties Union and the ACLU Foundation. Learn more about the distinction between these two components of the ACLU. User Agreernen I Privacy Statemen I FAGS I Site Map 2 of 2 4/7/08 10:50 PM IL A GRASSROOTS LEADERSHIP SOUTH CAROLINA FAIR SHARE SPECIAL REPORT PRESCRIPTION FOR RECOVERY: Keeping South Carolina's Prison Health Care Public and Making It Better by Marguerite G Rosenthal, Ph.D. Grassroots Leadership South Carolina Fair Share 400 Clarice Avenue 1338 Main Street Suite 400 Suite 301 P.O. Box 36006 P.O. Box 8888 Charlotte, NC 28236 Columbia, SC 29203 704-376-9206 803-252-9813 www.gr.qissrootsleadership.org www.scfairshare.org June 10, 2004 M-AN PRESCRIPTION FOR RECOVERY: Keeping South Carolina's Prison Health Care Public And Making It Better Executive Summary As a follow-up to our earlier Prescription for Disaster: Commercializing Prison Health Services in South Carolina,this report is focused on important issues that the South Carolina Budget and Control Board should consider as it fulfils its legislated mandate to complete a study comparing the current public prison health care system with privatization before the South Carolina Department of Corrections [SCDC] awards any contract. We are very concerned that SCDC proposed privatization apparently before conducting any objective study of its own and seemingly proceeded on ideological convictions rather than on objective realities. Prison health care is fundamentally a public responsibility both legally and morally, and we maintain that SCDC should retain it. There are ongoing reports of deplorable health care provided by the three commercial entities that have submitted bids for SCDC's health care system. For example, the State Auditor in Vermont has just released a report that states that Correctional Medical Services has over-billed the state for non-existent staff and off-formulary psychotropic drugs;the state's losses amount to almost $830,000. The Idaho Department of Corrections has launched three different investigations into the activities of its contractor, Prison Health Services. The third company, Wexford Health Sources, cancelled a 5-year contract with Pennsylvania last year, hoping to extract more money from that state. Two studies that have compared prison health care costs among different states show clearly that South Carolina's costs are already lower than most and that public systems are less costly than privatized ones. A 2003 study by PriceWaterhouseCoopers found that South Carolina's expenditures were over$1,000 (or 113) less expensive than the average of six southern states. In general the second study, conducted by Jacqueline Moore and Associates, demonstrates the financial advantages of public systems, though the author is associated with private prison health care. The current SCDC health care system has both strengths and weaknesses. Its principal strength is its cadre of dedicated and loyal medical staff, its state-run laboratory and its own, efficient pharmacy. However, because of job freezes and cumbersome hiring practices, the Department has left many positions unfilled, and the system is under great stress. Proactive hiring policies, creative approaches to filling positions in underserved prisons and streamlining bureaucratic regulations will ease these difficulties. Some of these will save money by making the system more efficient. Prison health care is a public responsibility and needs sufficient support to ensure the health and safety of prisoners and, ultimately, the public. L if Prescription For Recovery I AM-AN PRESCRIPTION FOR RECOVERY: Keeping South Carolina's Prison Health Care Public And Making It Better Introduction and Update This report is a follow-up to our earlier one, Prescription for Disaster: Commercializing Prison Health Services in South Carolina.' Governor Mark Sanford and his Corrections Department Director, Jon Ozmint, have advocated privatizing prison health services in South Carolina. Prescription for Disaster documented the dangerous and expensive prison health care services provided by for-profit, private corporations in South Carolina from 1986-2000 and elsewhere. This report is being written as the South Carolina General Assembly has required the Budget and Control Board to complete a study comparing the current public prison health care system with privatization before the South Carolina Department of Corrections awards any contract. We are writing this report in large part because the South Carolina Department of Corrections [hereafter SCDC] apparently conducted no thorough study of its own before making the decision to privatize its prison health care system to a private company. Especially in light of the fact that SCDC had a troubled experience with its partially privatized health system in the past, we are convinced that an objective examination of the many complex components of any prison health care system must be conducted before a major decision such as privatization goes forward. Part of this needed examination must include the experiences of the State of South Carolina and other states and localities that have or have not privatized their prison medical services. Prescription for Disaster reported numerous examples of deplorable health care provided by the three commercial health care companies that have submitted bids for South Carolina's prison health care contract award, Correctional Medical Services [hereafter, CMS], Prison Health Services [hereafter, PHS] and the smaller Wexford Health Sources. Since the first report was written, we have found other, recent examples of private prison health care companies' failures. In several cases, states and counties have had to bear expensive financial costs as a consequence of both contract non-compliances and medical malpractice. News articles, official reports, and lawsuits against these companies are easily located on the internet. We cite only a few, but egregious, examples below: Correctional Medical Services ➢ In 2003,the Philadelphia Inquirer published a report that charged that CMS was failing to inform and treat prisoners suffering from hepatitis C in New Jersey's prisons. A class action suit against CMS and the NJ Department of Corrections on these same grounds was filed, and the state was forced to pick up the costs for treating the hepatitis epidemic, estimated to cost between$4.5 and $8 million in 2003.2 ➢ Vermont's State Auditor has just released a review of that state's Department of Corrections' contracts, including one with CMS. CMS was I2 Prescription For Recovery criticized for billing for non-existent staff, needless expenses for off-formulary psychotropic drug costs and failure to submit required quarterly and annual financial reports. The state's losses amounted to almost $830,000.3 The Vermont report's serious charges concerning CMS' practices echo those of South Carolina's 2000 Legislative Audit Report.a ➢ The U.S. Justice Department's Civil Rights Division, along with the American Civil Liberties Union of Eastern Missouri, is currently investigating CMS for alleged inadequate medical attention and care that may have led to the premature death of several prisoners at the state's Vandalia women's prison.5 Sister Frances Buschell, prison coordinator for the Jefferson City Roman Catholic Diocese and a regular presence in the Vandalia prison, reports that CMS routinely imposes obstacles to care. She has observed the following problems: women must line up in the early morning just to fill out a request to be seen by medical personnel, and only a fraction of them actually complete the necessary forms because the time allotted for this task is much too short; women wait 4-6 months for cancer treatment, at which point their cancers have worsened and may have become terminal; two women have lost sight because their meningitis was misdiagnosed as a psychiatric problem;pain medication has been denied when needed; and records have been falsified. Buschell states that there is frequent turnover of medical staff and that the doctors are inept.6 Prison Health Services ➢ PHS, which has contracts with many county jails as well as a few states, apparently ignored the obvious serious health problems of several Lee County, Florida prisoners. A December 2002 article reported that several prisoners died either in the jail or very shortly after being released. A lawsuit was filed in US District Court on a claim of one former prisoner who was paralyzed from "botched medical care."' ➢ The same Florida newspaper report also cited the New York City Comptroller who, in expressing grave concerns over the medical care being provided at the infamous prison on Rikers Island, noted nation-wide criticism of PHS and questioned whether PHS should be permitted to provide services in New York State.8 Nurses at Rikers Island have claimed that PHS had so reduced staff that employees and prisoners were both at risk.9 ➢ A nurse who once worked for PHS in St. Lucie County, Florida claimed that she was fired for refusing to participate in illegal and unethical practices, including ignoring a request for medication, verbal abuse of prisoners, antagonizing mentally ill prisoners and falsifying medical records.10 ➢ In 2002, the ACLU filed a class action against Clark County, Nevada and PHS for dreadful conditions in the jail's medical unit and inadequate medical care that caused"widespread harm." Mental health treatment was called "atrocious and Prescription For Recover7JOW 3 uncivilized" and the jail was said to have no protocols for treating chronic illnesses." ➢ In April, 2004, Idaho's Corrections Director expressed dissatisfaction with PHS, its contractor. The Department has launched three different investigations, and the Director was quoted as saying: "We have employee management issues, communication issues and accountability issues."12 Wexford Health Sources ➢ In June, 2003, Wexford cancelled a 5-year contract with Pennsylvania after only a little over one year, hoping to renegotiate for more money.13 ➢ There are recent allegations that seven deaths in Florida's jails—including one of a 56-year-old minister and Purple Heart Vietnam veteran who died when he did not receive dialysis on time—are attributed to poor medical treatment by Wexford." ➢ An article in an Illinois paper reported that Wexford obtained a$114 million contract with the Illinois Department of Corrections after the company contributed $10,000 to Governor Rod Blagojevich's campaign. Wexford had the lowest bid but also did not have the highest score in the Department's evaluation.15 What Should the Budget and Control Board Study? We applaud the General Assembly's requirement that privatization should not be entered into headlong and without an objective evaluation of its true costs. At the same time, we have concerns that the focus of the Legislature's mandate to the Budget and Control Board is on costs alone. South Carolina's prison health care system is already among the least expensive in the country, and it is hard to imagine that any more financial reductions can be extracted from the system without harm. Indeed, because of frozen positions within the SCDC health care system, the current costs are below what they should be. Further, what commercial companies promise is often not what they deliver, as our earlier report documented. Private companies have a record of promising to reduce costs and then wangling for increases once they have gotten their contracts. They have avoided or refused to provide needed health care services such as diagnosing and treating hepatitis C, and they have reloaded onto the public systems health services that they consider too costly. Comprehensiveness and quality of services should, in other words, be important foci of any comparison, difficult as such a detailed study might prove to be. We are concerned that SCDC's decision to privatize its prison health care system is based upon the ideological assumption that privatization must be more efficient and cheaper rather than upon an evidence-based analysis. In this regard, we are very concerned that SCDC did not carefully study the needs of its prison health care system as well as the serious problems and financial losses associated with its previous CMS contract before launching into another privatization initiative. 4 JJ Prescription For Recovtery�§���J _E E An EU__ E There are fiindamental services that are the duty of the public sector to provide. Purchasing automobiles and copying machines from commercial dealers is one thing; states do not manufacture and supply themselves with these sorts of items. Running prisons, on the other hand, is an age-old function of the state. Caring for those in prison is a public obligation stemming from the consequences of prisoners' losing their liberty. Selling this obligation raises the specter of incompetent care, profits to corporate executives and shareholders—most of whom live and spend out of state—paid for by South Carolina taxpayers, and exploitation of prisoner-patients. SCDC is fortunate to have many dedicated health care professionals. Some of them have thought carefully about needed changes to improve the delivery and efficiency of the prison health care system. These improvements would result in reducing bureaucratic functions so that more time can be spent in direct care. At the same time, these professionals recognize the difficulty the Department has had in attracting and employing personnel in some of the more remote parts of the state and they have suggestions to remedy these difficulties. This report will briefly review of what is known about several prison health systems. It will then relate some of the suggestions that have come from current SCDC personnel. The SCDC Prison Health Care System in Comparative Perspective South Carolina's Prison Health Care Costs are Comparatively Low Already In January, 2003,the accounting consultant firm, PriceWaterhouseCoopers, issued a report, Interstate Survey of Health Care Costs for Inmates, commissioned by the Georgia Department of Corrections. This report, which compared prison health costs for Alabama, California, Florida, Georgia, Mississippi, South Carolina, Texas and Virginia, found that the average cost per prisoner in these states in FY02 was$3,523. In South Carolina, the cost was nearly one-third less: $2,280. Only Alabama and Mississippi spent less than South Carolina that year. Alabama's system was a troubled privatized one that has since switched providers, but Mississippi's was public at that time.16 Another study was conducted by the firm, Jacqueline Moore and Associates, in 2003. Moore was a co-founder of Prison Health Services (PHS) but currently has ties to Corrections Medical Services [CM S].17 PHS and CMS are the two biggest for-profit prison medical companies, and both have submitted bids to the SC Budget and Control Board. Moore's study compared FY 2002 per prisoner health costs for 8 states. A comparison of average costs as published in this report is reproduced on the following page. Prescription For Recovery 5 Comparison of Average Healthcare Cost Per Inmate FY 200218 STATE ADP COSTS EXCLUSIONS COST/INMATE/YR Idaho(PHS) 6297 $11,800,000 Cat Limits$25K/ $1,873.91 Inmate/Yr Delaware(First Cor- 6800 $17,000,000 Unlimited $2,617.65 rectional Medical) Wyoming(CMS) 1070 $46,869,000 Aggregate Cap $6,419.63 Maine(CMS) 2170 $9,200,000 Pharmacy $4,239.63 Vermont(CMS) 1436 $6,200,000 Pharmacy $4,317.55 North Dakota 1032 $7,500,000 No Exclusions $7,267.44 (Self Op) South Dakota 2954 $10,200,000 No Exclusions $3,452.92 (Hospital Based) Utah(Self Op) 5700 $18,288,233 No Exclusions $3,208.19 Utah 5700 $17,088,233 Budget Minus $2,997.93 Amount Returned to UDOC Note that Vermont, Maine and Wyoming contracted with CMS and paid between$4,318 (without pharmacy charges) and $6,420 (capped)per prisoner per year. The chart above also shows that Utah, a publicly provided system, had lower per prisoner costs than the privatized systems, $2,998 (after funds allocated for clinical services but used for other purposes were returned to the Department of Corrections). Although Moore's report made some recommendations for further efficiencies, it concluded that Utah had a cost-effective and comprehensive system that should not be privatized. This report, available online at http://www.le.state.ut.us/interim/2003/pdf/00001128.pdf, could well be useful to those reviewing South Carolina's prison health care system. Another cost comparison is contained in the following: In FY 2004, CMS was charging Missouri $7.84 per day per prisoner or $2,861.50 annually. This amount exceeds South Carolina's costs and is more than double the charges of$3.70 per prisoner per day originally contracted for in 1992.19 6 Prescription For Recovery :J01 These cost analyses demonstrate that, on its face, public prison health care is less expensive than privatized prison health care. There may, of course, be some unique situations in each state's system. Nonetheless, these studies certainly suggest that South Carolina will not save money by contracting with for-profit prison health companies. We suggest that privatizing will not save money because a commercialized system necessarily adds costs since it must reward its investors with profits and its executives with salaries much higher than public sector compensation. To make up for these added costs and charge the state less, commercial companies must reduce the quantity and quality of services, as the many stories of inadequate care cited above attest, and/or they must substantially reduce the compensation of those actually providing the services. In the latter case, dollars are removed from South Carolina's economy. If costs can be saved by better management, as private companies often claim, there is no reason that the SCDC cannot itself become more efficient (see below for some suggestions). We suspect, however, that having already suffered several severe budget cuts,there is very little else that can be cut out of the SCDC prison health system. Except as an initial loss leader(as has happened elsewhere), how can a commercial company possibly save dollars and reward its investors and executives except by improperly rationing services? South Carolina's Prison Health Care Costs Have Been Dropping Not only is South Carolina's prison health system relatively inexpensive, it has also been reducing its average costs per prisoner. While most of the states in the Southeast region saw increases of between 3% and 16% between FY01 and 02, South Carolina's costs dropped by 14.7%, nearly 3 times more than the only other state to see reductions, Tennessee.20 We note that CMS pulled out of its contract with SCDC during FY 2001. In other words, when South Carolina took its prison health care system back from a private company, its costs went down significantly. We urge future investigators to look carefully into these reductions to determine their causes and evaluate their promises for the future. We observe that South Carolina's total payments to outside medical providers such as general hospitals (presumably for emergency services and complex health services) was nearly 1/3 of its prison health care budget in both FY01 and FY02.20 Perhaps this significant expenditure is related to the fact that SCDC continues to contract with Columbia Care, run by Just Care, Inc. of Alabama, a private health care corporation, for some of its prisoner patients. According to SCDC's chief accountant, private care was estimated to cost the state $20,000 more per prisoner per year than care in the prison system's infirmary.22 Continued use of this facility and its associated costs is certainly an area that should be examined further. Can SCDC's Prison Health Care System Improve? As noted above, personnel in the current, public SCDC prison health system have hands-on knowledge of their system and have offered this writer some suggestions for greater efficiency and cost savings. Some of these suggestions are presented below, but—again—we urge that future investigators consult with a variety of medical and mental health care givers, pharmacists and laboratory technicians, particularly those currently working within the SCDC system, to gain a i—p—r- escription For Recovery more detailed description of their work while also gaining important information and recommendations for improving the system. To begin with strengths, SCDC medical personnel point to several important factors: ➢ Dedicated and loyal employees; ➢ A system of medical directives that has functioned well in the past (but may be slipping currently); ➢ A state-run pharmacy that runs efficiently and in a cost-cutting manner; ➢ A state-run laboratory which, similarly, is cost-efficient since testing is done in-house; and ➢ Strong specialty clinics. There are a number of weaknesses, however, that are frequently mentioned. These include (and will be further elaborated on, below): ➢ Insufficient direct medical personnel, including doctors, nurses, nurse practitioners and psychiatrists; ➢ Cumbersome hiring practices that dissuade applicants from seeking positions at SCDC; ➢ Hiring freezes that have left clinics understaffed, creating tremendous burdens on the loyal staff remaining and costing SCDC substantial financial outlays for per diem hiring; ➢ Few medical protocols in place, resulting in wasted effort and time in getting approvals for prisoner care; ➢ Quality of care that is not always up to standard; ➢ An inadequate administrative structure with poor linkage and communication between the Central Office and individual clinics; and A An overly bureaucratic system that wastes time and effort that could better be spent on patient care. Sueeested Solutions Staffing problems appear to be at the core of the various challenges facing SCDC's medical services and, indeed, have provided at least one of the rationales for seeking to commercialize the system. These problems fall into two categories: staffing qualifications and appropriate levels of responsibility; and hiring protocols to attract new personnel. Specifically, the following recommendations have been suggested by current SCDC health staff: 1) Staffing the clinics: Currently, there appears to be an over-emphasis on having physicians in each clinic. Since nurse practitioners are licensed to prescribe medication, having a nurse practitioner in each clinic would be cost effective and is more likely to result in eliminating the large number of physician vacancies. 2) Hiring medical and mental health specialists: Staffing all the prisons, particularly those in rural areas, is admittedly a difficult challenge. However, scholarship or loan/payback arrangements for students attending South Carolina's public institutions of higher education who are training for relevant specialties, such as psychiatrists, psychologists, psychiatric nurses and social workers, could assist in filling some positions. Under this arrangement, students receiving scholarships would be obligated to work for the SCDC for a fixed amount of time after they receive their advanced training. Some may, of course, g Prescription For Recovery in choose to remain in the prison health system after they have fulfilled their mandatory obligations. A related suggestion is that SCDC partner with the University of South Carolina's Medical School and its public universities to arrange for internships. Under appropriate supervision, interns can greatly augment SCDC's medical and mental health staff. 3) Recruitment methods: More aggressive outreach,particularly through active use of the internet, is needed. Commercial prison health care companies use the internet for recruitment; SCDC should use the same techniques. We note that North Carolina's Department of Corrections, which contracted with CMS to staff its prisons in remote,rural areas, found that the private company was no more successful than it had been and therefore terminated the contract.2 3 4) Hiring incentives: SCDC should consider instituting sign-on bonuses to recruit medical and mental health personnel who agree to work in hard-to-staff prisons. 5) Streamlining the hiring process: The current hiring process takes too long and is overly bureaucratic. Especially since there is a nursing shortage in South Carolina, the red tape involved in hiring must be cut so that appropriate applicants receive job offers quickly and are rapidly moved into their SCDC positions. Allowing medical personnel in each facility to hire staff would greatly shorten the lag time and administrative costs currently involved in employing new personnel. 6) Unfreezing medical records personnel positions: Nurses currently have responsibility for medical records,taking time away from nursing. Shifting responsibility for medical records duties to other personnel might make sense since they are often not fully occupied with their primary responsibilities. 7) Developing_a pool of nurses: Instead of hiring per diem nurses from a private and expensive nursing agency, SCDC could develop its own pool of nurses to fill in as needed in several institutions. 8) Allowing positions to be filled before a resigning employee leaves: Being proactive about replacing personnel would assure that positions are filled in a timely fashion. 9) Filling vacant pharmacist positions with technicians: Licensing requirements allow for 3 technicians for each pharmacist; hiring technicians this way would be cost-effective. Streamlining the bureaucracy to make medical care more efficient would allow medical personnel to attend to patient care instead of filling out request forms and waiting for approvals from central office. A key to achieving more efficiency involves having nurses use existing Medicare protocols, thus eliminating the need for a physician's having to review and approve consultations and treatment regimens. A specific recommendation offered by a current nursing supervisor is to purchase the computerized version of McMillan, Robertson Utilization Review and to make it available to all Prescription For Recovei MMM91 SCDC clinic physicians and nurse practitioners to save time on routine cases. Another suggestion is to revamp the nursing hierarchy, eliminating a supervising nurse at each location and allowing the head nurse to serve in that capacity with, perhaps, 3 or 4 nursing supervisors for the whole system to whom the head nurses would report. In general, there needs to be an evaluation of the true staffing needs to determine how many supervising staff are actually needed in order to reduce costs associated with higher ranking medical personnel. Mental health screening and appropriate placement are crucially important to the functioning of the prisons. Mental health professionals such as social workers and psychiatric nurses can conduct mental health screenings, considered very important in light of the large numbers of mentally ill and substance-dependent prisoners. These professionals can be hired at less cost than psychiatrists and clinical psychologists who are currently required to perform these functions. Re-instituting the accreditation process would assure that medical services conform to standards. Assuring objectivity in evaluations is crucial. With oversight to insure that they remain objective, using available SCDC medical staff for audits is cost-effective, particularly because they can establish appropriate policies and procedures as part of this function. There needs to be more accountability in the system; currently too many decisions pertaining to health care are left to each warden. Establishing an independent medical services review body that can receive, investigate and respond to questions and complaints related to prison health care services raised by prisoners, their families, employees and advocates is vitally important to improve the prison health care system and assure that health care is properly delivered and crises are avoided Hidden Costs of Inadequate Prison Health Care Systems States are obligated by a U.S. Supreme Court decision to provide prisoners with adequate health care.24 Even when prison health care systems are privatized, the states continue to bear this legal responsibility. Prison health care is not just a matter of personnel, physical facilities and medications. There are the costs of attorney and legal fees, insurance and settlement payouts associated with malpractice claims and lawsuits. If the prison health care system is under-funded and under-staffed, lawsuits will abound, and the state will have costly damage awards. While the current costs to the State of South Carolina are not known to us, it should be cautionary that officials in one New York County suggested doubling their insurance protection when it privatized its jail's health program.25 And then there is the matter of public health. Nearly every prisoner will be returning to his or her community someday. Thus, prison health care is truly a public health concern. Because of the crowded conditions of their confinement and their poor health status, prisoners are particularly susceptible to communicable diseases such as tuberculosis, hepatitis C and HIV/AIDS. It is therefore critical that they get appropriate treatment. If they do not,these illnesses will spread to the general population. To save lives and to protect public health, health care should be efficiently but also adequately provided. These are all important factors to consider when evaluating who should be delivering prison health services. 10 Prescription For Recovery MAN 1 0 E Conclusion The current SCDC prison health care system is not expensive when compared to other state systems. Privatizing does not save money. Indeed, giving state money away to out-of-state executives and shareholders results in further squeezing the health care system. SCDC has a cadre of dedicated and thoughtful personnel, many of whom have devoted much of their professional lives to caring for the state's incarcerated population. The system appears to be functioning fairly well, but, as should be clear from the briefly outlined suggestions above, there are many areas that can be greatly improved. These suggestions, if explored in greater detail and implemented appropriately, may result in financial savings to the state. At the same time, we caution that the system appears to be seriously understaffed, particularly in the area of primary caregivers. Reducing bureaucratic functions will make more current personnel available to perform caring functions, but more personnel are clearly needed. The changes outlined above have been suggested by current SCDC medical staff. These professionals are in the best position to provide details about their current ideas as well as to provide additional suggestions for improvements in the system in which they work. Establishing a task force composed of current staff representing different specialties and geographical areas of the state and outside medical experts familiar with institutional health care is, we feel, the best way to evaluate how to improve the SCDC health care system both to make it more cost-efficient and to enhance the quality of care it provides. ABOUT THE AUTHOR: Marguerite G. Rosenthal is a Professor of Social Work at Salem State College in Salem, Massachusetts. She holds a Ph.D. in Social Work and Social Welfare from Rutgers University. She has received awards and grants from the National Institute of Mental Health, the National Association of Social Workers and the U.S. Department of Health and Human Services. Early in her career, she served as a juvenile probation officer with the Onondaga County Probation Department in Syracuse, New York and as supervisor of field staff at the State c f New Jersey's Department of the Public Advocate. She has published and presented widely on issues of social policy,privatization, managed care, welfare reform, residential care, juvenile corrections and faith-based initiatives. She is currently serving as Senior Research Fellow for Grassroots Leadership while on sabbatical from Salem State College. L 11� Prescription For Recovery ii References 1. Rosenthal, M.G. (2004). Prescription for Disaster: Commercializing prison health care in South Carolina. Grassroots Leadership/South Carolina Fair Share. 2. Fazloliah, M. and Lin, J. (2003). Hepatitis C treatment may cost N.J. millions. Philadelphia Inquirer (Jan. 12); Selan, E. (2003). HepC class action suit filed in U.S. NJ District Court, retrieved at http://www.hcvinprison.org/doscs/classaction100103.html on 5/31/04. 3. Ready, E.M., (2004). Keys to Success: Improving accountability, contract management and fiscal oversight at the Department of Corrections. (May 26). 4. South Carolina General Assembly, Legislative Audit Council(2000). A review of the medical services at the SC Department of Corrections. (LAC/SCDC-98-7), retrieved at http://wwww.state.sc.us/sclac/Reports/20000/SCDS.htm on 4/1/2004. 5. Dreiling, G. L. (2003). Some inmates tell horror stories about healthcare at the women's prison in Vandalia. Some didn't live to tell their tales. Riverfront Times(Oct. 15); Denise Lieberman, Legal Director, ACLU of Eastern Missouri(personal communication, May 24, 2004). 6. Sr. Frances Buschell (personal communication, June 1, 2004). 7. Hoyem, M. (2002). Dying in Lee County Jail. News Press(Dec. 22). http://www.news- press.com/news/loca state/0212222jailmedicine.html. 8. Ibid. 9. Service Employees Union Local 1199 (2001). Bad to worse at Rikers (June). 10. Pollio, M. (2002). Ex jail nurse sues healthcare company. Retrieved at http://allnurses.com/ forums/showthread.php?postied=168051 on 5/28/04. 11. Geer Thevenot, C. (2002). Class-action lawsuit: Jail's care deficient, ACLU says. Las Vegas Review-Journal(May 26). 12. n.a. (2004). The Idaho Statesman (April 6). Retrieved at http://www.flpba.org/private/ rap_phs.html on 6/1/04. 13. Ransom, L. (2003). Wexford ends inmates' health care contract. Pittsburgh Tribune-Review. (June 7) Retrieved at http://www.pittsburghlive.com/x/tribune-review/yesterday/ print_138547.htm1 on 3/9/2004. 14. Barg, J. (2002). Scandals r us: Seems the city can't find a prison health care provider without a troubling past. Philadelphia Weekly (Sept. 4). Retrieved at http:// wwww.philadelphiaweekly.com/article/asp?A.rtID=4195 on 5/28/04. 12 Prescription For Recovery 15. O'Connor, J. (2004). State awards prison contracts to Blagojevich contributor. State Journal Register (March 9). 16. PriceWaterhouseCoopers(2003). Georgia Department of Corrections: Interstate Survey of Health Care Costs for Inmates. (January 21), p. 4. 17. Broughton, A. (2003). Privatization study advisor under scrutiny. The Salt Lake Tribune (July 16). Retrieved at http://www.strib.com on May 28, 2004. 18. Moore, J. and Associates (2003). Analysis of cost and service within the Utah Department of Corrections Bureau of Clinical Services. "Discussion Draft"prepared at the request of the Office of Legislative Fiscal Analyst (November 18). Table 10. p. 37. 19. Dreiling, G. L. (2003). Some inmates tell horror stories about healthcare at the women's prison in Vandalia. Some didn't live to tell their tales. Riverfront Times (Oct. 15). 20. PriceWaterhouseCoopers (2003). Georgia Department of Corrections: Interestate Survey of Health Care Costs for Inmates. (January 21), p. 7. 21. PriceWaterhouseCoopers (2003). Georgia Department of Corrections: Interestate Survey of Health Care Costs for Inmates. (January 21), p. 8. 22. The Post and Courier (Jan. 27, 2003). Corrections closes 5 prison infirmaries. Retrieved at http://www.charleston.net/cgi-bin/printme.pl on March 31, 2004. 23. Keith Acree, Public Information Officer, North Carolina Department of Corrections (personal communication, April 5, 2004). 24. Estelle v. Gamble, 429 U.S. 97, 103 (1976). 25. Martineu, K. (1999). Privatization of jail infirmary advances. The Times Union (November 24). Prescription For Recovery 13 L ww.grassrootsleadership.org www.scfairshare.org --ismPrescription For Recovery VL% LIAm._Q. WALKER, M. D. OFFICE OF THE HEALTH SERVICES DIRECTOR f ' DIRECTOR 50 Douglas Drive,Suite 310-A Martinez,California CONTRA COSTA94553 Ph(925)957-5405 _ HEALTH SERVICES Fax(925)957-5401 March 7, 2008 Federal Glover, Supervisor District 5 Jolui Gioia, Supervisor District 1 Chair, Contra Costa Board of Supervisors Contra Costa Board of Supervisors 315 E. Leland Road 11780 San Pablo Avenue#D Pittsburg CA 94565 El Cerrito CA 94530 Dear Supervisors Glover and Gioia: During the meeting of the Professional Affairs Cominittee of the Contra Costa Regional Medical Center of February 21, 2008, you requested comparative information concerning the hospital's employee benefit package relative to other area hospitals. The following is an attempt to be responsive to that request. Summary: Employee Benefits as a percent of salary (excluding OPEB Liability) Fiscal Year Ending 2006: Contra Costa Regional Medical Center: 81.70% Alameda County Medical Center: 62.22% Santa Clara County Medical Center: 59.18% Doctors Hospital San Pablo: 44.20% John Muir- Walnut Creek Campus: 48.25% John Muir- Concord Campus: 47.22% All hospitals in California are required to annually report detailed financial and utilization data to the Office of Statewide Health Planning and Development (OSHPD). This report is based on a uniform reporting system (i.e., all hospital reports are prepared in a uniform manner,using OSH.PD definitions). Hospitals are required to submit reports, within four months of the close of their accounting period. After receipt by OSHPD they are desk audited, and the corrected data are input into the OSHPD database. In addition, if individual hospitals wish to revise their data they may. Periodically (at least annually), data files are posted on the OSHPD website. The most recent file available on the website covers hospital accounting periods ending during 2006. According to the Accounting and Reporting Manual for California Hospitals, which governs the reporting system, employee benefits are defined as, "A pension provision, retirement allowance, °f �l • Contra Costa Alcohol and Other Drugs Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health • Contra Costa Health Plan Contra Costa Hazardous Materials Programs •Contra Costa Mental Health • Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers - Federal Glover, Supervisor.DisLrict 5.,Chair John Gioia,Supervisor District 1 Contra Costa Board of Supervisors March 1.2008 Page 2 insurance coverage,paid vacation, sick leave, and holiday time off or other cost representing a ZD present or future return to an employee,which is neither deducted on a payroll nor paid for by the employee." The OSHPD data should be viewed within the context of being self-reported and unaudited. There are no consequences for erroneously filed reports. Accordingly, we contacted Doctors Hospital, Santa Clara Valley Medical Center and Alameda Medical Center to validate and confirm the: salary and benefit numbers contained on the attached schedule were accurate. All facilities either corrected or validated the numbers contained on the schedule. The John Muir Concord and John Muir Walnut Creek data are taken directly from publicly filed OSHPD statements. The data are believed to be accurate but due to timing constraints independent validation did,not occur. Please note OSHPD data does not provide Salary and Benefit information at the detailed employee classification level, e.g. Nursing. Please advise if additional information or clarification is required. Siinncerely, �L Patrick Godley Chief Operating Officer/Chief Financial Officer Contra Costa Health Services cc: William Walker, M.D., CCHS Director and Health Officer Jeff Smith,M.D., CCRMC and Health Centers Executive Director Jolui Cullen, County Administrator Lisa Driscoll. County Finance Director Linda Asheraft, County Labor Relations Manager �o Q 0 u OD �Q o CD e o .n m ° r:vi o ni vi v lu G c o — vmmc N M m 7°�N M O cl j, QNi � V �vMi� cc m d cr O O ti E C N O M O O ° � 10V'm N l!1 U u1 a' M ry ry v O c c0 U � a � � -�-+0 uimvi ory ry LO ` O mm m Mr.,CD to o C o E o ° v L n v ¢ U c m - o ro s UU !� � Mrn� V'V/MN V� m c o d U1 v V ) U E v� Q� Oi N N 16 Ll 16 tD N Lr yp1j hj cr ° �p A ° m rnNmmmNMN N y rn o E Q L C m m V1 m°)N C NZ. O V M ° O O v V" a �ryN � ° oD m o Cl) 41 N � c � Lo � m c pl Q1 E a o c .n w L •�� rr N V L o O t] C � Q) � a�aa000000 0 _v W O m1p N Qui n N C vry N 0 O ry } fu > U 12 ry C A o U o U v v 9 N m�����wm�vv�i c v m 1O vii in c o er ri in�c M m N Ln m.--i M Ci ^�t0.-i N 'O �.-� C m mrvo mNc�coo co o d a � E a c o o w m U v o m m C N N p d C c `o v c a c w n a y Y v o E a o a w v >w a> >w a v a :c mv°Ji o ami u a' N Y>y a.r N N N V� c 0 L A L° �� J D u t�v coi u m 2 in �E„U c c v v m 2 L7 E V m y E n .�.. c c°1i o vi v v= w '^ c v o` EEa,m N o >.a EEmm c v m 3 E v v a_ v 4Q o E u (0 007 " E E °v v w o N d q X l E E °v w v o o•• U U a to m»i w���KoH VI m»�i wD�a!C� p Z__ ma_'o ThC Yale.Hippolytic: The Clinic and the Prison: Priva(tiza)tion by Jeremy Kessler Page 1 of 5 The Yale Hippolytic»Volume iVolume iVolume iVolume O1Volume 01 »Issue 1Issue 2Issue Wssue 04Issue 07 The Clinic and the Prison: Priva(tiza)tion Privatization funds and ensures the brutal treatment of America's imprisoned. BY JEREMY KESSLER "When the state deprives people of their liberty, essential services cannot be contracted or outsourced. To do otherwise makes private what in this age should be public, and sacrifices individual health (and in the case of suicide, survival) to profiteering. " -John M. Brickman,former executive director, New York City Board of Correction, 1971-1975 "[Mjen for days chained in place by their feet and fists. . . the routine alternation between punishments and sedatives, detention/injection, dungeon/valium (oh, tranquilizing morality); car thieves that one transforms at the age of twenty into delinquents for life, suicide attempts nearly every night. " -Michel Foucault In 1971, the prisoners at Attica state prison in New York revolted. One of the stated reasons for the insurrection was lack of adequate health care.After local and federal law- enforcers had stormed the prison, after a massacre, the corpses of 43 prisoners and guards were not the only signs of the massive failure of the penal system. A wave of lawsuits,filed both by prisoners and guards of Attica, led to a 1976 U.S. Supreme Court ruling which demanded that local governments ensure proper medical care for the prisoners of their penal institutions. It was a victory for both the aggrieved administrators and recipients of punishment. But the ruling was also an opportunity, providing capital a new role to play on the stage of a decreasingly public society. Two years after the Court ruling, Doyle Moore, a nurse from Delaware, established Prison Health Services, the first for-profit prison health-care company. The financial burden that had been placed on city and state governments by the Supreme Court decision in favor of adequate medical services could now be shunted onto a private company, which, through the legerdemain of free-market principles and corporate management strategies,would minimize costs. The health of nation's prisoners was to be a compromise between conscience and commodity. Since Moore started Prison Health,the for-profit prison medical industry has boomed, and is currently responsible for the health care of 40 percent of nation's inmates. Prison Health Services alone,the largest for-profit provider, administers care 10 percent of the U.S. prison population. Moore's corporate child has grown so large by buying up number of smaller providers, who sometimes were operating in regions where Prison Health had been and left, often amid accusations of abuse, mismanagement or gross negligence. Indeed, the system of for-profit medical not necessarily conducive to the pursuit of adequate medical treatment for prisoners. Many local governments have the policy, or http://www.hippolytic.com/printable/2005/05/the clinic and the_ prison priv.html 4/7/2008 The Yale Hippolytic: The Clinic and the Prison: Priva(tiza)tion by Jeremy Kessler Page 2 of 5 even the requirement, of awarding contracts to the lowest bidder. The understandable desire to limit the expenditure of tax dollars results in a bidding frenzy—there are less than ten for-profit prison medical companies in the U.S. and in a given region they furiously underbid one another to attempt to snag a contract. Dr. Michael Puisis, the editor of"Clinical Practice in Correctional Medicine," explains: "It's almost like a game of attrition,where the companies will take bids for amounts that you just can't do it. They figure out how to make money after they get the contract." The result of this underbidding,when it comes time to stretch the profit margin, is the marginalization of adequate prison health care.A series of exposes in the New York Times has recently cataloged Prison Health Services problematic tenure as health care provider for a number of New York State's prisons, including New York City's entire penal system. Before Prison Health Services received a $254 million, 3-year contract in 2001 to provide medical care for New York City's inmate population, the company already had a well- established record of negligence elsewhere.A spate of ten deaths through 2001 in upstate New York jails under PHS management led to an investigation which cited, as the NYT summarizes, "medical staffs trimmed to the bone, doctors underqualified or out of reach, nurses doing tasks beyond their training, prescription drugs withheld, patient records unread and employee misconduct unpunished." The State Commission of Correction has since urged Attorney General Elliot Spitzer to shut down PHS in New York— as the company is run by business executives not doctors, the Commission contends that it has no legal authority to practice medicine at all. Frederick C. Lamy, chair of the commission's medical review board, explains that"the lack of credentials, lack of training, shocking incompetence and outright misconduct [of the PHS-employed medical staff is] emblematic of PHS Inc.'s conduct as a business corporation, holding itself out as a medical care provider while seemingly bereft of any quality control." Before entering New York State, PHS' record was no better. Over the years, they have spent tens of millions of dollars settling lawsuits and paying fines, and have had contracts ended in Georgia, Maine,Alabama, Florida and a number of other states. In one incident in Georgia, Diane Nelson, a 46 year old mother, died of a heart attack when nurses neglected to order the heart medication Ms. Nelson's doctor had prescribed. The Times reported that as Nelson was in her death throes, a nurse told her to "Stop the theatrics," and later admitted to joking to the staff, "We save money because we skip the ambulance and bring them right to the morgue."The company's CEO, Michael Catalano, has argued that these incidents are commensurate with the incredibly difficult service his company provides: "What we do is provide a public health service that many others are unable and unwilling to do." New York City concurred in spirit with Mr. Catalano when it gave PHS the company's biggest-ever contract. During its NYC tenure, PHS.has employed ten psychiatrists with foreign medical degrees without state certification, five doctors with criminal convictions, and 14 doctors with state or federal disciplinary records. These staffing failures have led to problematic results — 15 inmate suicides in the last four years, 6 coming in a six-month period in 2003 alone. That rate of suicide is both higher than the rate prior to PHS' entry http://www.hippolytic.com/printable/2005/05/the clinic and the prison priv.html 4/7/2008 The Yale,Hippolytic: The Clinic and the Prison: Priva(tiza)tion by Jeremy Kessler Page 3 of 5 into the NYC system, and higher than that of Los Angeles County's penal system,the largest in the nation.All six of the 2003 suicides were committed by inmates who had not been convicted of any crime, having been detained prior to trial or on violations. The New York Times correctly notes that the correction system is so susceptible to suicide because "the mentally ill have flooded New York's jails ever since they city cracked down a decade ago on lesser crimes like vagrancy." Up to a quarter of the NYC jail population on an average day has "psychological ills." Of course, the flood of the mentally ill in the last decade resulted from huge cuts in funding for mental hospitals across the country in the decades before. When hospitals were shut down, the mentally ill took to the streets, and have since been re-absorbed into the clinical-penal system at a different point of entry. That structural shift from care to punishment, motivated by cost-cutting, suggests a more general paradigm in which to understand Prison Health Services'costconscious abuse. The Supreme Court ruling in 1976 that catalyzed the private prison medical-care industry cited inadequate medical care as a form of"cruel and unusual punishment." Indeed,the cost-cutting sought by public governments, and practiced by private companies like PHS, licenses a form of punishment supplementary to incarceration itself. Such supplementarity is nothing new— poor medical care, sub-human living standards, and inmate-inmate rape; an-unoffi cial but utterly uninhibited practice, have long been the punitive remainders in the calculus of incarceration. But post-1976, the privatization of prison medical care reveals a public attempt to shun an expensive responsibility,both minimizing cost and installing greater levels of opacity in the prison system,through recourse to corporate discipline. The move has resulted, inadvertently or otherwise, in a further merger of the roles of the clinic and the prison, a merger in the spirit of a time which has witnessed the incarceration and execution of the mentally ill, as well as the enlistment of doctors into the ranks of the intelligence community. For although the expansion of private industry into the public sphere of judgment has proven a suffi cient cause of the conspiratorial discipline of cruel medicine, it is not a necessary cause — other alibis have arisen in recent years for the union of the clinic and the prison. In June 2004, the International Committee of the Red Cross spent nearly a month at the U.S.- run detention center at Guantanamo Bay.A memo quoting details from the report, which by agreement with the U.S. government was to remain confi dential, was leaked to the New York Times early this year. According to the reported contents of the memo, doctors collaborated with military personnel in the course of interrogations, providing information about prisoners' "mental health and vulnerabilities."The Behavioral Science Consultation Team, a group of military psychologists, acted as the conduit for this information, meeting regularly with interrogators to discuss the prisoners' medical records. When informed of this arrangement, Leonard S. Rubenstein, executive director of Physicians for Human Rights,told the Times: "The use of medical personnel to facilitate abusive interrogations places them in an untenable position and violates international ethical standards." Rubenstein also worried about the possibility that medical staff "engaged in calibrating levels of pain infl icted on detainees." http://www.hippolvtic.com/printable/2005/05/the clinic and the prison priv.html 4/7/2008 The Yale Hippolytic: The Clinic and the Prison: Priva(tiza)tion by Jeremy Kessler 'age 4 of 5 In this case, the intersection of medicine and punishment was not directly facilitated by business and professional negligence but rather by a rhetoric of terror and the concomitant implementation of torture, or as the Red Cross stated, acts "tantamount to torture."At Guantanamo, the fusion of the medical and incarceratory occurred as a result of the "necessity"of interrogation. In New York and elsewhere, the fusion of the medical and the incarceratory occurred as a result of the "necessity" of cost-minimization. The obvious differences between these scenes of fusion are apparent. Nevertheless, the Red Cross in its conclusion has already begun to deconstruct the binaries of intent versus accident, purposive versus collateral result, and all other forms of logic deployed to excuse the abuse of the incarcerated body. "The construction of such a system,"the Red Cross argued, "whose stated purpose is the production of intelligence, cannot be considered other than an intentional system of cruel, unusual and degrading treatment and a form of torture" [my italics]. Although there is much doubt as to how much valuable information U.S. interrogators gleaned from Guantanamo prisoners, surely some "intelligence"has been gained, however important or unimportant it might be. In the event that any intelligence was produced, the Red. Cross' statement insists that regardless of that production, which was the "stated purpose" of interrogation,the medical-penal collaboration and its resultant system can-still be accused of"intentional" cruelty. The key to the Red Cross' determination does not-rely on a differentiation between "stated purpose" and"intent" but rather on the inconsequentiality of purpose in the face of the overwhelming obviousness of that purpose's (secondary) result —the infl iction of"cruel, unusual and degrading treatment." If one gives the interrogators the benefi t of the doubt that they are not purely sadists, one agrees that the purpose to produce intelligence was their primary intent. If one gives the interrogators the benefi t of the doubt that they produced some information, one can even agree that information was the primary result. Nevertheless, the Red Cross statement contends that the secondary result of the interrogations —the infliction of cruelty—was so powerfully clear a priori that that infl iction must be considered intentional a priori. Exactly the same argument can be produced re: cost-minimization and the privatization of prisons. The primary intent of cost-minimization is to spend fewer tax dollars on prison health care. Fewer tax dollars have been spent on prison health care. Nevertheless, one could demonstrate that the resultant lack of care is so rampant and was so predictable (if not in 1978 when PHS was founded, then in the present day when the company is still being given contracts), that the infl iction of what the Supreme Court itself ruled was "cruel and unusual punishment"must be considered intentional — intentional not just at the private level of the corporation but at the public level of the government of the people that licenses the private mismanagement. Neither economic efficiency nor "winning the war on terror" as goals obviate the guilt of the cruel in the pursuit of those goals. The failure of prison health care due to economic interest retains a function homologous to the abuse of the patient by the doctor/torturer,the eugenicist, the human experimenter. We must disabuse ourselves of the intentional fallacy which dictates that the former-is an abstract, structural problem, whereas the latter are crimes of personal and institutional cruelty. We must be affected equally by cruel effects, whether those http://www.hippolytic.com/printable/2005/05/the clinic and the prison priv.html 4/7/2008 Toe Yale,Hippolytic: The Clinic and the Prison: Priva(tiza)tion by Jeremy Kessler Page 5 of 5 effects were originally effected because of cruelty or because of greed. The privation visited upon prisoners, or upon the poor, or upon the so-called mentally ill, is not an economic problem. It is a political one, political in the oldest sense of the word —that which calls the bodies of a citizenry to account for their actions. The same goes for other potential failures perpetrated by society in the name of efficiency—social security disintegration, the undermining of public education, or the subversion of Medicaid. These possibilities are not solutions to structural problems but new avenues for the expression of a form of incivility, of cruelty, of greed. Privatization, the vector for many such "solutions," deforms questions of the political and of civic morality through its sterile, economic rhetoric. For at the same time that privatization in its current form depends on economic argumentation and operates in the sphere of what we call "economic policy,"its "intentional"agenda, intentional in this new sense of the a priori obviousness of the cruel result, is not solely economic and shares an intentionality with certain non-economic policies. Secret abductions, governmental opacity, and manufactured intelligence information are all attempts to "privatize" — they all constitute an attack on the public sphere, the scene of politics. They do not constitute one side of a political controversy,but are a subversion of the ability to practice politics itself,the ability of a citizenry to interact as equal and open bodies. This application of the privatization "logic"to the foreign political sphere would actually, in a reversal, allow an economization of foreign, seemingly"[geo]political" problems,just as it allowed a politicization of the domestic, seemingly"economic" problems. In this gesture, a certain argument would trace a thread through the "war on terror,"the war in Iraq, Halliburton, corporate interests, energy defi cits, and so on,to link the attempt to funnel public money to private corporations domestically with the attempt to further corporatist interests internationally. Such a performance will not be attempted here. In either case,the attack on the public indicated by"privatization"cannot be blamed solely on a few moguls, robber barons, or pro-industry politicians. In any sort of democracy that provides the degree of freedom that Americans still have, the attack on the public must to some degree have been licensed by the public. Privatization can only mask and motivate public evil. It is still public tax money that goes to fund private corporations. It is the public and its appointed ministers who allow them to operate.American money has funded, and American policy has licensed, the torture of foreigners. American money has funded, and American policy has licensed, the brutal treatment of America's own imprisoned citizens. 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