Committee Hearing, April 21, 2004

COUNCIL OF THE CITY OF PHILADELPHIA PUBLIC HEARING COMMITTEE OF THE WHOLE FY '05 OPERATING BUDGET - - - - Room 400, City Hall Philadelphia, Pennsylvania Wednesday, April 21, 2004 10:00 a.m. - - - - BILL 040255 - An Ordinance adopting the Operating Budget for Fiscal Year 2005. PRESENT: COUNCIL PRESIDENT VERNA, Chair COUNCILWOMAN JANNIE BLACKWELL COUNCILMAN DARRELL CLARKE COUNCILMAN W. WILSON GOODE COUNCILWOMAN JOAN KRAJEWSKI COUNCILWOMAN DONNA REED MILLER COUNCILMAN MICHAEL NUTTER COUNCILMAN BRIAN O'NEILL COUNCILMAN JUAN RAMOS COUNCILWOMAN BLONDELL REYNOLDS BROWN COUNCILWOMAN MARIAN TASCO - - - - V A R A L L O Incorporated Litigation Support Services Eleven Penn Center 1835 Market Street, Suite 600 Philadelphia, Pennsylvania 19103 215.561.2220 215.567.2670 I N D E X BILL 040255 JOHN DOMZALSKI, Health Commissioner ROB DUBOW, Budget Director......... 118 BRENDA SHELTON DUNSTON............. 151 MICHALE COVONE, Health Dept........ 163 ALBA MARTINEZ, Commissioner, DHS... 179 CHERYL RANSOM, DHS................. 186 ELLEN STEIKER, DHS................. 190 DAVID FAIR, DHS.................... 193 JOHN ZANIER, DHS................... 210 ANNMARIE AMBROSE................... 225 ROBERT HESS, OESS.................. 238 RICHARD SHAEFFER,OESS.............. 300 CAROL TRACY, OESS.................. 318 JOAN SCHLOTTERBECK, Commissioner, Public Property................ 333 JAMES MULLER, Fleet Management..... 345 BOB FOX, Fleet Management.......... 349 3 04/21/04 - WHOLE - BILL 040255

Good morning, everyone. This is the continued public hearing of the Committee of the Whole regarding Bill No. 040255. The first department to be testify will be the Health Department. Good morning. COMMISSIONER DOMZALSKI: Good morning, President Verna.

Welcome. Please identify yourself for the record and proceed with your testimony. COMMISSIONER DOMZALSKI: Good morning, President Verna and Members of Council. I'm John Domzalski, Health Commissioner. I appreciate the opportunity to present the Health Department's budget request for Fiscal Year 2005. I'm joined at the table by Carmen Lemmo who is the Director of Finance and Administration for the Department of Public Health. And, President Verna, with your permission, I would like to introduce two of my senior staff Deputy Commissioner Carmen 4 04/21/04 - WHOLE - BILL 040255 Paris who is behind me to my left. An=d Deputy Commissioner Paris oversees a wide variety of programs and services in our department. Next to her is newly promoted Assistant Health Commissioner, Joseph Cronaur who comes out of the advocacy community, had been heading up our AIDS Activities Coordinating office and has a long and extensive history in coordinating community-based organization work. Not able to be with us is Dr. Joanne Godley who is the Medical Director for the Department of Public Health. As such, she's the Chief Medical Officer for the Department, and of particular note to Philadelphia is Dr. Godley led the process by which Philadelphia became one of the few -- one of the seven cities in the nation to receive a Steps grant which is a substantial amount of money for prevention services at the community level in Philadelphia. Dr. Godley worked with Gwen Foster in a wide variety of voluntary and non-profit health agencies and advocacy groups in the community to do that. 5 04/21/04 - WHOLE - BILL 040255 So thank you very much for that indulgence.

Thank you, Commissioner. 5 million in the Grants Fund, of which 105 million is in the General Fund and 70 million is in the Grants Fund. 5 million comes from City to tax supported funds. The Department's budget will support 1,017 positions, 761 in the General Fund and 256 in the Grants Fund. This represents a reduction of 10 General Fund positions. The staff reductions will be taken in administrative areas that do not affect services. I am pleased to report that the Department's recommended budget for FY '05 maintains key performance and service indicators comparable to those of FY '04. During FY '04, the Department undertook major 6 04/21/04 - WHOLE - BILL 040255 initiatives aimed at improving and protecting the health of the community and incorporating a neighborhood perspective on citywide health status indicators. We will continue these initiatives in FY '05. The Health Department administers a wide range of essential public health services for Philadelphians. These include primary care at eight neighborhood health centers, monitoring and control of communicable diseases, operating a specialty clinic for the treatment of sexually transmitted diseases and coordination, funding, and oversight of HIV/AIDS programs. The department coordinates, funds, monitors child health services, including infant mortality reduction, prenatal and family planning services, childhood lead poisoning control and prevention. We're responsible for a range of environmental protection services, including monitoring of pollutants and enforcement of local, state, and federal environmental regulations as well as the regulation of the local retail food 7 04/21/04 - WHOLE - BILL 040255 industry. In addition, the Department maintains oversight of the Philadelphia Nursing Home and monitors the healthcare delivered in Riverview Home. The Health Department is also prepared to respond to threatened or actual bioterrorism events and is a partner with the Police and Fire Departments and the Office of Emergency Management in the City's overall emergency response structure. 2 million in emergency preparedness funding under the new Homeland Security Act. In keeping with Mayor Street's focus on the transformation of our neighborhoods, we have organized our data so that health status indicators so that the overall health of the City can be understood from the perspective of its neighborhoods. These neighborhood level data aided by the mapping technology and use by Philadelphia Safe and Sound continue to be used strategically and deploy and redeploy resources to areas of greatest need. These data range from immunization and lead 8 04/21/04 - WHOLE - BILL 040255 poisoning incidents to the occurrence of communicable diseases and chronic diseases such as diabetes and heart disease. The Mayor's vision is that while we focus on neighborhoods, we do not turn our backs on the businesses that are so important to the economic health of the City. Accordingly, in our regulatory activity, we're making our procedures and processes more understandable and user friendly while not compromising the public health objective of our regulations. I will now highlight some of our major accomplishments and challenges: Lead poisoning control and prevention in children. A new public health offensive against childhood lead poisoning began in April 2002 and will continue in FY '05. Thanks to the vision of the Mayor, the effort of Philadelphia Congressional Delegation, particularly Congressman Chaka Fattah, and the advocacy community, in particular Philadelphia Coalition for Children in Youth, PCCY, and the credibility of our 9 04/21/04 - WHOLE - BILL 040255 re-engineered lead effort, the funding anticipated in last year's hearing has been acquired.

Philadelphia's signature approach to intervening in cases of childhood lead poisoning, the Lead Abatement Strike Team, or LAST, continues to actively address all new cases and to not allow any new cases to become part of a backlog, while at the same time continuing to reduce the backlog which stood at 1,400 properties in April 2002. The map on the screen depicts what the backlog looked like in April of 2002. Not only was the growth of the backlog stopped, the backlog itself has been reduced to 573 properties, with a further reduction anticipated to 250 in 2005. That map shows the reduction to the backlog now standing at 573. The unprecedented close collaboration of eight City units in the government and the Lead Court combine to make the Philadelphia approach unique among programs across the nation in both structure and effectiveness. We've also secured funding to begin to take childhood lead poisoning to 10 04/21/04 - WHOLE - BILL 040255 the next level, which is primary prevention. In this regard, working with Philadelphia Citizens for Children and Youth, the National Nursing Centers and others, more than 900 new and expectant mothers have been visited so far in FY '04 by a nurse or trained outreach worker. The target for FY '04 is 1400 families. Clients receive a lead education presentation and their homes are evaluated visually with dust wipe samples, and those found potentially dangerous by a certified risk assessor are offered lead hazard reduction through a grant from the United States Conference of Mayors. In FY '04, 50 potentially dangerous homes occupied by new or expectant mothers have been identified and have had lead hazards reduced through this program. In FY '04, the Department plans to strengthen its partnership with the medical assistance managed care organizations to provide increased lead education to new mothers, increased lead screening of their infants and increased inspection of their housing units for lead 11 04/21/04 - WHOLE - BILL 040255 hazards. Infant mortality. Infant mortality is the measure of the number babies who die before one year of age per thousand live births. 4 in 2001, which is 9 the latest year for which data are available, 10 a decrease of about 25 percent. However, this 11 decline does not reflect the significant 12 disparities that remain among individual 13 Philadelphia neighborhoods. The map on the 14 screen depicts the infant mortality across the 15 City, with those areas in red posting the 16 highest infant mortality, often times as much as double the citywide rate. The Department addresses infant mortality through targeted programs. In addition to two federally funded Healthy Start programs, the division administers a wide range of home visiting, outreach and community education programs funded through Maternal and Child Health Title V Programs. For the coming fiscal year, we have redesigned these programs 12 04/21/04 - WHOLE - BILL 040255 in order to better reflect best practices as defined by the literature and national maternal and child health experts. This restructuring will provide us with increased control over individual programs, including and enhanced capacity to measure outcomes and to focus our efforts in neighborhoods that have the highest infant mortality. Childhood immunization. Philadelphia and other large cities in the nation have experienced decreases in the rates of childhood immunizations, due in part to the introduction of additional inoculation requirements, but only in part. In response to our determining that the citywide immunization rate had fallen from a high of 83 percent in 1998 to 70 percent in 2002, the Department set a goal to raise the citywide rate to 90 percent by FY '06. I am pleased to report that the latest national survey identifies that we have stopped the decline in immunization rates and, in fact, had begun a turnaround such that current survey results show that our levels risen to 80 percent.

13 04/21/04 - WHOLE - BILL 040255 That is the map we started with, President Verna, in 2002 that shows the immunization rates. The red areas are the areas that have been as low as 30 and 40 percent in those neighborhoods. The new map shows that because of strategic development and our outreach deployment in those areas, we've turned that around, eliminated the red area and indeed, according to the survey, begun to stop the decline and increase the immunization rates citywide. Chlamydia and gonorrhea. Like the rest of the nation, we are in the midst of an epidemic of sexually transmitted diseases among our adolescence 15 to 19 years of age. Unlike the rest of the nation, we've developed an aggressive approach to meeting this epidemic head on. That's a picture of the epidemic in the City of Philadelphia. The latest data confirmed that there are 9,000 cases of gonorrhea and chlamydia in this age group. With the courageous collaboration of the Philadelphia School District, we mounted an aggressive and nationally unprecedented 14 04/21/04 - WHOLE - BILL 040255 response in FY '03 which involved the provision of STD education in all public high schools, including offering voluntary testing on-site and follow-up confidential counseling and treatment. In the 2002-2003 school year, 30,000 students attended educational presentations with 19,600 children receiving voluntary testing. 8 percent of those cases were treated. So far in 2003-2004 school year, 15,000 students have fattened educational presentations with 9,400 availing themselves of voluntary testing. And I can tell you we've identified again 519 new cases previously undiagnosed asymptomatic cases of chlamydia and gonorrhea in this age group. The uniqueness of this undertaking, collaboration with the School District and the aggressive case finding, resulted in national recognition of this program as a model for other cities to consider. HIV/AIDS. While the number of new 15 04/21/04 - WHOLE - BILL 040255 and existing AIDS cases reports filed with the department in FY '03 remained relatively stable with a slight decrease from 1,160 in FY '02 to 1,126 in FY '03, the number of actual new diagnosis of AIDS has continued to drop with the advent of effective treatment from 958 of new cases in FY '02 to 888 new cases in FY '03. AIDS continues to disproportionately impact minority communities, with 78 percent of persons living with AIDS being of color. The Department has engage in a variety of activities to address these disparities. This past summer, the Department put out the competitive bid of the entire HIV prevention system targeting the highest risk neighborhoods with interventions that address the highest risk behaviors. Community-based organizations competed for the approximately $6 million available, and as a result, new interventions were established by mostly minority-controlled organizations in neighborhoods most impacted by HIV. This included making available free HIV testing at more than 50 sites across the City where 16 04/21/04 - WHOLE - BILL 040255 35,360 HIV tests were conducted during Calendar Year 2003. Additionally, the Department continues to fund community-based providers 6 through the Ryan White Minority AIDS 7 Initiative. This initiative, also 8 neighborhood-focussed, centers around the 9 Storefront Project with it's three walk-in 10 safe spaces providing services in Germantown, 11 West Philadelphia, and Kensington. The 12 storefronts are street-level, open-access 13 service sites providing a safe space geared to 14 walk-in traffic. They link people with HIV to 15 primary medical care, testing and counseling, 16 case management, substance abuse treatment, 17 prevention programs and other needed services. 18 During the past year, we served 1,587 19 high-risk people and people living with HIV through the storefront initiative, about half of which are women and children. The Department continues to operate and structure its animal control services.

And this is focused on responding to those issues that stray animals present in the City, 17 04/21/04 - WHOLE - BILL 040255 of which we have an overabundance. A variety of animals make wonderful pets and can enhance family and individual quality of life and well-being. However, when such pets are not cared for and managed responsibly, the result can be detrimental to the public health and safety. Accordingly, a new and more aggressive public awareness licensing and license law enforcement campaign will occur this spring and summer and into 2005. The Department of Public Health has a number of challenges: Insurance coverage for health center patients. It's well understood that the medical care and the services ancillary to its service delivery are among the most complex and expensive of the services needed by a community. The Department's eight full-service health centers depicted on the screen are the medical care providers to 100,000 Philadelphia children and adults who make about 320,000 patient visits a year. No 25 Philadelphian is denied care in our health 18 04/21/04 - WHOLE - BILL 040255 centers. Our ongoing challenge is to secure the cooperation of all of our patients in accessing available health insurance for which they may qualify. In FY '02, a full 64 percent of our patients were without insurance. A number of studies, including a recent study by the Institute of Medicine have shown that people without health insurance have worse health status than people with insurance. Yet many of the uninsured in our centers were insurable, including the children. Working to get insurance for those who are eligible, we reduced the number of uninsured visits to 60 percent in FY '03, and our projection for FY '04 is to reduce the number to 55 percent. Our goal for FY '05 is to reduce that number still further to 50 percent. While we will turn no one away, we must have the cooperation of everyone in making application for insurance for which they may be eligible. Prescription drugs. The debate as to how to make this essential element of medical treatment affordable wages across the 19 04/21/04 - WHOLE - BILL 040255 political spectrum and among those who rely on life-sustaining prescription medication. In counterpoint in this volatile situation is the Department of Public Health's Pharmacy Program which provides prescription drugs to all health center patients without charge and at a level without equal anywhere in the City and perhaps the nation. Our health center pharmacies will fill an astounding 546,000 prescriptions in FY '04. While most of these are for longstanding health center patients, we see with increasing frequency persons being referred from other health systems for this benefit. The volume imposed on health center pharmacy results in long lines in each health center every day and delays that have been as long as eight days in getting a prescription filled. Clearly, we need to do better. And better will require a much different approach if we are to provide reasonably efficient, safe, affordable pharmacy services. Possible options, including accessing the existing pharmacy network in the City, continued emphasis on insurable persons becoming 20 04/21/04 - WHOLE - BILL 040255 insured, and close structure of scrutiny of a potential structure of co-pays for prescription drugs designed and implemented so that the cost of improved services can be affordable while assuring that persons in our system are not deprived of life-sustaining medication because of inability to pay. Health system changes. In the past 10 years, we have seen closures of 8 hospitals in this City, and this past December, the announced closure of the Medical College of Pennsylvania. In the intervening months, there is evidence that we have not seen the last of significant changes in the private and voluntary health systems in the City.

These changes have healthcare, legal, city planning and economic applications, and we need a mechanism within City government to assess, understand, and respond to these changes. That's our health centers, City health centers. These are the non-City health centers in the City. And third slide will so the combination. At first there were eight city health centers and precious little else. 21 04/21/04 - WHOLE - BILL 040255 And now we have 17 non-City health centers. And when we put them together, we've got something like 27 health centers. And the question is that we're all out there serving essentially the same population. The big question is, is it a system? And that's something that we've got to explore very closely and carefully as we go forward in this new fiscal year. Adjustment of fees for license services. The fees for many of the Department's services in certain City licenses and permits have not changed since 1993, and the Department has been absorbing increasing costs of providing these services which have increased percent during this period. In 18 the coming days, the Department plans to 19 introduce to Council amendments to the Health 20 and Air Management Codes to adjust these fees 21 to cover the cost of providing these services. 22 Universal healthcare. This past 23 November, the electorate approved a change in 24 the City Charter placing responsibility on the 25 Health Commissioner to develop a plan for 22 04/21/04 - WHOLE - BILL 040255 universal healthcare for all Philadelphians. This is a significant responsibility in relation to a subject that is the focus of much debate across the country and at every level of government. In this context, we have begun this work. Management. The Department has had the excellent service of a large number of highly skilled and effective management and technical staff. Many of these individuals have retired and will be retiring in the months ahead. Our plans are in place to manage these changes through a variety of organizational and structural changes. Principal among these are our new management structure for our health center system involving the use of a new health center manager series and the deployment of regional managers to oversee multiple health centers and the physical and managerial consolidation of the major laboratories that are operated by the Department. When I was here last year, President Verna, we talked about the some of the changes 23 04/21/04 - WHOLE - BILL 040255 that we needed to make in management. And one of the things that we were grappling with was making our health centers more accessible by telephone to the public. And the big area that we were facing was the virtual inaccessibility of our appointment desk for people calling in to make appointments in the health center. It was so bad in terms of access to that appointment desk that people would abandon the phone use completely and essentially walk to the health center to transact business as opposed to using the phone. We got together with the Department of Public Property, Joe James in particular, and Carmen Paris and a number of people on my staff got together and scoped out a system where we might have a centralized call system for our health centers. And I can tell you, President Verna, that this year we've been able to get all eight health centers on a centralized call system. And that's a picture of our very excellent public service people who are receiving calls from the general public for appointments in all of our health 24 04/21/04 - WHOLE - BILL 040255 centers. Essentially, when you're calling, for example, a health center at Broad and Morris, that phone is ringing here in City Hall with the appointment book up on the screen for that individual; and the individual can actually make, reschedule, change or cancel an appointment. A tremendous change. We're beginning to monitor the impact of that. We have one of our health center directors, Mr.

John McGill, who's got the operating responsibility for this. I'm told that Mr. McGill has taken to walking around the health center and when he sees people standing in line to make appointments, he bets them a cup of coffee that they can pick up the phone and make an appointment quicker or change an appointment quicker than they can by standing in that line. And what I'm told is he's losing very few cups of coffee these days. So that's an example, President Verna, of some of the management changes. In conclusion, the Department of Public Health is moving forward and meeting longstanding and developing public health 25 04/21/04 - WHOLE - BILL 040255 challenges in new ways. We are meeting the budget challenges by bringing sound management principles together with creative program initiatives to preserve and improve the delivery of essential public health services to the people of Philadelphia. Thank you, President Verna, for the opportunity to present this testimony.

Thank you, Commissioner. I have a couple questions, but before I do ask them, I certainly want to compliment and applaud you and your staff for doing an absolutely fantastic job. Thank you so much. COMMISSIONER DOMZALSKI: Thank you, President Verna.

Commissioner, on of your testimony, you mention that your Department has organized data on health status indicators so that the overall health of the City can be understood from the perspective of the health of its neighborhoods. This data is aided by mapping technology in use by the Philadelphia Safe and 04/21/04 - WHOLE - BILL 040255 Sound and is used to strategically deploy or re-deploy to resources to areas of greatest need. Can you tell us how this data is used and what resources have been re-deployed? COMMISSIONER DOMZALSKI: Yes President Verna. I think our immunization strategy was a good example of that. We have traditionally looked at citywide indicators of how we're doing from an immunization perspective. What I asked staff to do is not to talk about the City, don't ignore the averages but tell me what it looks like in the neighborhoods, what does the immunization rate look like in the neighborhoods. And when we did that, we found that even though our overall City rate was at a dismally low 76 percent, that turned out to be good news because there were neighborhoods where it was below 50 percent. So what we did was take our outreach teams and have them reduce work in the neighborhoods where the immunization rates were very high to the neighborhoods where the immunization rates were very low. And by 27 04/21/04 - WHOLE - BILL 040255 focussing the outreach and moving those resources from areas where we already accomplished our mission but if we didn't look at it from a neighborhood perspective, we wouldn't have known that and moving them into the areas, such as zip code 26, to improve the rates there.

Is Safe and Sound still involved? And if so, are they under contract, and for what amount? COMMISSIONER DOMZALSKI: Safe and Sound does a number of programs very effectively particularly with our beacon and schools and after school programs. We support some services under contract with Safe and Sound, particularly some of our disease prevention services. We also partner with them, President Verna, around the report card. And I will tell you that what got my attention on this whole business of chlamydia and gonorrhea was when we began doing the children's report card and showing that the STD indicators for our children were so poor, we were at the lowest level, Level 5, and that 28 04/21/04 - WHOLE - BILL 040255 focus, that was a challenge. I will tell you we in public health didn't want to see that. But we decided, you know, the data were accurate, it's displayed there and what we're going to do is organize our resources to begin to battle that epidemic. So we worked with Philadelphia Safe and Sound on a number of fronts, particularly around children services and after school and beacon school programs.

So they are under contract. And can you tell me for what amount? COMMISSIONER DOMZALSKI: We are contracting in the Health Department, our largest contractor we have with them -- this is not the only contract that we have from City agencies, but from the Health Department it's a little over 500,000 that we fund particularly for tobacco prevention and cessation programs. Mr. Lemmo tells me it's 578,000.

Thank you. Lead paint removal has been an area of great concern to Councilmembers, as you 29 04/21/04 - WHOLE - BILL 040255 know. And over the last few years, we have modified your budget in order to decrease the backlog. When do you anticipate the backlog will be eliminated? COMMISSIONER DOMZALSKI: We anticipate that the backlog will have been reduced from 1400 -- it's any 570-something now. We expect that by the end of Fiscal Year '05 for the backlog to be at 250 and probably by the middle of '06 for it to be eliminated completely.

That's great. Commissioner, how long does one have to wait for an appointment to see a physician at our health centers. COMMISSIONER DOMZALSKI: Well, it depends on the service, President Verna. One of our performance measures is a number of appointments that are available in three weeks. What our focus is, I think we're looking at somewhere around 76 percent of the appointments being available in three weeks. That's of all the appointments. When you 30 04/21/04 - WHOLE - BILL 040255 break that down, you see a number of differences. In our prenatal program, that might be three weeks, maybe four. Family planning might be two weeks. When we look at adults, for adults for just a routine visit, that ranges from health centers from -- I have appointments available today at Health Center 5. However, at Health Center up in the far 10 Northeast that might be a three-month wait up there for adults who do not have an urgent medical program. If there's an urgent medical program, it's an entirely different story. On the other hand, for children, we can get children in in a couple days across the system, so we have ample capacity for children. The adult piece does concern me quite a bit. One of the things that we're going to do is we're going to enhance that system that I had on the screen there about our operators taking central call. And each, we're able to access right now the appointment books for each health center. What I want to do is be able to look at a program where we're 31 04/21/04 - WHOLE - BILL 040255 able to display the whole system in front of an operator so that each operator can input into the system and make changes immediately so that if a patient does call from the Northeast and says, "My God, it's 70 days until you get an appointment." We can say, "Well, if you don't mind traveling a little bit, we can get you an appointment tomorrow or even this afternoon at Health Center 5 at 20th and Berks." Right now, the system, it's a little cumbersome to do that, but that's what we're doing. The other piece of it is, we have to look at how -- patients are telling us how they want to use the health centers. And we're telling them how we want them to use it. And they're winning. We might as well just figure out how best to accommodate this service and see whether or not there's ways in which we can adjust some of our initial appointments and how we bring people in for that first contact.

Do you 32 04/21/04 - WHOLE - BILL 040255 have any indication at all as to how many patients we've seen at the health centers in the last year, for instance? COMMISSIONER DOMZALSKI: How many people were served?

Yes. COMMISSIONER DOMZALSKI: Well, we serve 100,000 individuals, and they will make approximately 320,000 visits in a year.

Commissioner, in your testimony, I see that our health center pharmacies will fill an astounding 546 prescriptions in FY '04. Councilwoman Tasco and I introduced a resolution which has not been scheduled as yet and it resulted from what we saw on 60 Minutes on two different occasions. And that was that many of the cities and states are now having their prescriptions filled in Canada for their city employees. Can you tell me how much it cost to fill 546 prescriptions? And what do you think of the possibility or the idea of pursuing the issue of having prescriptions filled in 33 04/21/04 - WHOLE - BILL 040255 Canada? COMMISSIONER DOMZALSKI: In answer to the first question, President Verna, I will tell you, the price of medications, just the drug itself, runs probably somewhere just under $8 million a year. Then we have the price of pharmacists and then support 9 staff, and that's probably another 2, 2 and a 10 half million dollars on top of that. So we're 11 talking about a 10 or 11 million dollar issue 12 here with pharmacies. 13 Now, the pricing of all of this is 14 complicated. If you could bear with me just a 15 little bit, I can parse that out for you 16 somewhat. We enjoy -- because of the kind of health service delivery system we are, we enjoy the ability to purchase drugs at a very reduced cost. It's called the 340-B Program. It's under the Public Health Service Act. And it permits a very aggressive price discount to be made to programs that serve impoverished indigent communities such as our health centers. To understand the value of that, we have to talk about what's called AWP, which is 34 04/21/04 - WHOLE - BILL 040255 Average Wholesale Price of drug. That's a benchmark by which all prescription plans are based. For example, maybe the City employees program there's some discount from AWP. AWP is an average. And often times what the chain or the pharmacy will charge the prescription plan will be the following: They'll charge you for the drug at AWP minus a percentage plus a filling fee. Well, the difference between what AWP is and what pharmacies typically acquire the drug at is percent. There's about a 17 14 percent margin there. 15 We purchase drugs at a much more 16 attractive rate than that. Our price under 17 340-B pricing is approximately 56 or 57 percent below AWP. And so there's that part of it. In terms of the Canadian drugs, the Canadian system, I understand there's somewhere between a 30 percent price advantage and maybe a 50 percent.

Fifty. COMMISSIONER DOMZALSKI: Other 35 04/21/04 - WHOLE - BILL 040255 cities -- Sarah Haecker on my staff has done some research on this and identified that states of Minnesota, for example, and Wisconsin have posted on their web site pharmacies in Canada that they think are safe and places from which pharmaceuticals could be purchased at a discount price. I just heard the former FDA Commissioner David Kessler this week talk about the fact that it's against the law to do is that, that there are no safety standards to guarantee the safety of drugs purchased outside of the United States. Well, we're finding that the difference in all of this is really the price, not the pill. Because when you look at some of the manufacturer, for example, some of our major drugs like Lipitor a large portion of the drug Lipitor that comes into the United States is manufactured in Ireland.

And some of them are manufactured in Canada. COMMISSIONER DOMZALSKI: The whole business with the Medicare prescription drug 36 04/21/04 - WHOLE - BILL 040255 plan, you can see the ads on television, nobody understands it because it's so complex. On the other hand, the centers for Medicaid services CNS has now posting on its web site information about what -- in fact, I think they're even breaking it down to the pharmacy level so you could access their web site and say, Look, if I'm on drug X on a regular basis, they would give you the pharmacies in your surrounding area and the prices at which that drug is being sold. So there's a lot of activity here around this issue of drug pricing and the pharmaceutical delivery system.

Well, according to some information that we received, there are a number of cities and states that are sending their prescriptions to Canada. And the cities are really saving millions of dollars as a result of that. And according to what we saw, the drugs are safe because, as you say, most of them are produced outside of the States. Commissioner, I'll just ask one last 37 04/21/04 - WHOLE - BILL 040255 question because I know that Councilwoman Tasco has been waiting very patiently. For the last couple of years, it has been said that the healthcare center at Broad and Lombard would possibly be sold because the building is so inadequate. What is the status of that? COMMISSIONER DOMZALSKI: The health center at Broad and Lombard, we call it -- it's our health administration building. There's really three major functions in the building. The health center is on the first floor, the administrative offices for a number for our programs disease control on the second. And public health laboratory is on the third floor. That building sits on property that does not belong to the City. A good chuck of it --

It does not belong to the City? COMMISSIONER DOMZALSKI: Does not. We lease it --

It's 38 04/21/04 - WHOLE - BILL 040255 privately owned? COMMISSIONER DOMZALSKI: Yes. It comes to us by way of the Johnson estate that we lease this for on an annual basis. And our current lease with the Johnson estate expires in 2007 or 2008. When that lease expires -- right now I think we're paying $4,000 a year for that land. When that lease expires, we would expect that we would be paying market rates for that land. In addition to that, that building has just been a plague in terms of its maintenance, in terms of being able to work in there. We need to outfit our laboratory much better so that we can do bioterrorism kinds of work, but we cannot invest more money in the laboratory in that building. It will not support it. So our plan is to move out of there, one, the building doesn't work; two, we're going to los3 the lease on the site; and three, we probably are going to be able to better serve all of our public health functions and we're going to make sure we don't inconvenience the public in any new place that we move. 39 04/21/04 - WHOLE - BILL 040255

I'm sorry, when is that lease up, '07?

Either '07 or '08, President Verna. I'll confirm that for you.

Commissioner, thank you very much. The Chair recognizes Councilwoman Tasco.

Thank you. Is that the what John G. Johnson estate? COMMISSIONER DOMZALSKI: I'm sorry, ma'am.

What estate is that, the John G. Johnson? COMMISSIONER DOMZALSKI: All I know is the first Johnson. I don't know if it's -- I think there's an art collection.

John G. Johnson. COMMISSIONER DOMZALSKI: Yeah, you're right.

Thank you. I have a number of questions for 40 04/21/04 - WHOLE - BILL 040255 you, Commissioner, and I just like to begin with your statement in the testimony about the decrease in General Fund positions, but I'm 5 somewhat confused. On of the budget 6 book we have, it appears that there was an 7 increase of 37 employees? 8 COMMISSIONER DOMZALSKI: I think 9 what we're looking at is -- there are two 10 figures in terms of the number of employees. There is the budgeted figure for FY '04 and then there's the increment run which we run in November. So there's the increment run in November of '03. For example, the budgeted positions in the General Fund for '04 are 771. The increment run is 695. So what we planned to do, though, is to fill up to number of positions there -- 66 positions in FY '05. We show that as an increase of 66 positions, but it's not compared to what's budgeted, it's compared to what was in filled in November of '03. It's an awkward accounting way to show these numbers. The bottom line is that we'll end up with a net decrease of 10 positions across the department. 41 04/21/04 - WHOLE - BILL 040255

Explain that to me again. COMMISSIONER DOMZALSKI: When we show our budget in the General Fund, we show how many positions that we had budgeted for FY '04 when we began this fiscal year, which is 771. The increment date of November -- the City does, the accounting people take a snapshot. We never have all positions filled that we anticipate filling for a variety of reasons; people leave, we're slow in filling the positions for a variety of reasons, people are hard to get. So what we do is take a snapshot in November about how many of those 771 positions did you actually fill, Commissioner, you actually have filled at this time. And this November, it was 695 in the General Fund. And what we planned for in '05 then is to fill 761 positions, which looks like an increase of 66 positions compared to the '03 increment run, but it us is an actual decrease of 10 positions from the budgeted number. I will tell you, this makes sense 42 04/21/04 - WHOLE - BILL 040255 to --

Nobody. COMMISSIONER DOMZALSKI: To people who do --

No one. No 7 one. I don't understand it. I'm looking on where it says list of positions, General Fund, and you have a lot of positions in the Grant Fund. I'm looking on of the budget book. COMMISSIONER DOMZALSKI: The 37 positions, Councilwoman?

Yes. COMMISSIONER DOMZALSKI: That's compared, again, to the increment run in November. We're actually showing a 37 position increase because that's the number of positions that are vacant, that were vacant as of November. So we don't want to let that go, we want to fill those positions right up to what we're budgeted for, because these impact the health centers and we want to be very careful with that.

You had 423 43 04/21/04 - WHOLE - BILL 040255 budgeted in '04. I'm looking on . COMMISSIONER DOMZALSKI: Yes, ma'am.

And you so a budgeted number positions of 423 in '05. COMMISSIONER DOMZALSKI: Yes.

And the difference from -- let's go back. You had actual positions in '03 of 400. You budgeted 423 in '04. And I don't know what increment run is in November of 356. Is that the number of positions you had? COMMISSIONER DOMZALSKI: Yes, ma'am.

Now so how many positions do you have now? COMMISSIONER DOMZALSKI: We have 386.

386? COMMISSIONER DOMZALSKI: Yes, ma'am

And you anticipate filling 423? COMMISSIONER DOMZALSKI: Yes, ma'am.

So you budgeted for them doesn't mean that you're going to fill them, right? 44 04/21/04 - WHOLE - BILL 040255 COMMISSIONER DOMZALSKI: Our intention is to fill them.

Are these all new positions? COMMISSIONER DOMZALSKI: They're not new, no. They're a variety. Some of them are very important clerical positions. Some of them are nursing positions. Some of them are pharmacy positions. There are a variety.

Of the clerical positions, are they all civil service? COMMISSIONER DOMZALSKI: Yes, ma'am.

Would some of them come from other departments in the City? COMMISSIONER DOMZALSKI: No. 17

So they would be advertised and the test would be given and there would be no transfers from other departments? COMMISSIONER DOMZALSKI: People could. I mean, they could access the list. I don't know most of these open competitive. The promotions I guess would be in the department. But I think others would be open 45 04/21/04 - WHOLE - BILL 040255 competitive.

Could you tell me how then -- COMMISSIONER DOMZALSKI: Especially the entry level ones. They could come from other departments. But they'd have to get on the Civil Service list.

So then could you explain to me how do you account for General Fund reduction of 10 people? COMMISSIONER DOMZALSKI: How we're doing that?

Yes. COMMISSIONER DOMZALSKI: Yes, ma'am. We have three positions from facilities management. We are going to centralize the facility maintenance under Public Property, so we'll be giving up three positions there. There's a couple of clerical positions and there are a couple of administrative positions. For example, I have an administrative officer in environmental protection. Actually, it's a contract administrator that won't be filled. So it's 46 04/21/04 - WHOLE - BILL 040255 across the department, but it's at levels that will not --

Will they be Grants Fund or General Fund? COMMISSIONER DOMZALSKI: General Fund.

So you support in the various grant programs you have General Fund dollars supporting staff? COMMISSIONER DOMZALSKI: Yes.

In the grants program portion of the budget, you have General Fund money? COMMISSIONER DOMZALSKI: No, just grants.

So environmental protection, is that General Fund? COMMISSIONER DOMZALSKI: It's a combination of General Fund and Grant.

And so any individual coming out of the program that's funded with grant money would be the employee that is funded by the General Fund? 47 04/21/04 - WHOLE - BILL 040255 COMMISSIONER DOMZALSKI: No. Our reduction would be in General Fund positions but not in the Grant Fund.

All right. Thank you. I'm still not clear. On of your testimony, you stated that the health department has begun the work of drafting a plan for universal healthcare. I'd like for you to describe what work has begun and what is your timetable and plan for the completion of this Charter mandate. COMMISSIONER DOMZALSKI: Let me tell you, Councilwoman Tasco, that if I had gotten -- and I'll just be candid with you. If I had gotten an opportunity to volunteer or not volunteer to do this, I don't think I would have volunteered to do this. The Charter has been made the responsibility of the Health Commissioner to develop a plan for universal healthcare, something that nobody else has been able to do nationally or at the state level. Having said that, my colleagues and I in the Department have decided this might be 48 04/21/04 - WHOLE - BILL 040255 just an excellent opportunity to begin to pull this community together that's got things to say about and understand about healthcare and its access. And we've had an initial meeting. I will say it was a good meeting, but it wasn't a good meeting. It was a good meeting because we had probably different segments 9 of the community in there ranging from people 10 from the Philadelphia Unemployment Project to 11 organized labor to health insurance and people 12 in the middle of the spectrum there. And we 13 had people said at the end of that meeting 14 that this is the first time a conversation 15 like this has ever taken place in this City about an issue such as health insurance. Indeed, one of the insurers said that, "If you had ask me to come to the meeting like this three years ago, I would have said no. And if I did come, I would have said there's no place for me at this table." That person said that, "Yes, there is. I understand it now. Health is a community affair and we've got to pull our information together and identify what things we can do." 49 04/21/04 - WHOLE - BILL 040255 We cannot as Philadelphians change federal policy. Hopefully, what's going to have when we have presidential, you know, politics in the election everyone's got a healthcare plan. Maybe that's going to help us. The State's got a lot of leeway in this in terms of how they fund services. There are things we are do. There are things we can do. We can look at our health systems here as we displayed up there in terms of our 27 health centers. But we can also look at how we're being impacted by national trends across the board. When Carol Rogers and I looked at the number of uninsured, uninsured in Philadelphia, we were astounded to learn we have 136,000 uninsured people. And what was even more astounded than that, in the two years that elapsed from the time the first study was taken on that until these data became available, 20,000 more uninsured were added to the rolls. And the tragedy of that is 80 percent of the uninsured are employed, people who are employed who cannot access 50 04/21/04 - WHOLE - BILL 040255 health insurance. Either they don't get it from their employer anymore or they get less of it from their employer and they are required then to pay more into it as a co-pay. So we've got to take all these pieces together and say, "Look, what is the picture in Philadelphia?" And don't forget, there are increasing numbers of individuals who are not only insured but our system says you will never get insurance.

I understand and we all understand the difficulty in doing this. I think the intent -- and I can't speak for Councilman Cohen -- was to have Philadelphia begin to think about what we can do that could possibly serve as a model to stimulate national thinking. I mean, from small little acorns do big trees grow. And looking at developing a plan that, certainly, we can influence federal policy if it's done the right way. But I guess my question is, is your dialog ongoing and have you developed an outline for an action plan or a process for 51 04/21/04 - WHOLE - BILL 040255 how you meet the Charter mandate? COMMISSIONER DOMZALSKI: We have. We've engaged someone to help us lead that to begin to staff that, to pull the data together to begin to pull meetings together. We envision in this actually bringing in Councilmembers to this. We had a meeting last week with Councilman Cohen to talk about this. We also envision have meetings at the neighborhood level in the communities to see how they're impacted, get a perspective there that we wouldn't have just looking at it from our advantage point. So we're going to pull all these pieces together, including most of the people who came into Council and testified in favor of this because everyone has got something to say about this. I believe two things: One, all healthcare is personal. And two, health definitely is a community affair.

Councilwoman, you can finish you line of questioning on this. Councilman Ramos has been waiting, so we could always come back to 52 04/21/04 - WHOLE - BILL 040255 you.

I just want ask you, you said you pulled someone in to help you do that. Who is that? COMMISSIONER DOMZALSKI: Dr. David Grande (ph).

What is his background and experience? Is he an employee of the Health Department? COMMISSIONER DOMZALSKI: No, he's not. Dr. Grande has worked at the policy level in Washington on healthcare issues and health policy issues. He's familiar with that area. Importantly, he's also a practicing internist, so he understands patient care from the delivery point and also is able to bring some resources together from -- he's associated with the Woodrow Wilson School of Public Policy at Princeton. Is able to bring some of those resources together.

How was he selected? COMMISSIONER DOMZALSKI: Actually, through a process, I think it was suggested to 53 04/21/04 - WHOLE - BILL 040255 me from somewhere in the advocacy community, we brought a couple of people together to talk about does this make sense for us to go in this way. I'm talking about people outside the Health Department. We had some questions about what was his background and preparation. We shared his resume. We talked about it. And when we came out of it, we decided we've got to get going on this. Dr. Grande appears very competent. He's got the right background and experience. We think we need to be get moving, and I think that that's a good approach and so that's the way we're going.

Thank you. I have some more.

Thank you. The Chair recognizes Councilman Ramos.

Thank you, Madam Chair. Good morning, Commissioner. COMMISSIONER DOMZALSKI: Good morning, Councilman

I want to thank 54 04/21/04 - WHOLE - BILL 040255 you for being one of many department head and agencies and boards that reached out to me. I'm the newest member of City Council. And that has helped me understand your needs and your concerns, especially within the deficit that this City faces, this government faces at this time. No health centers are closing, is that true? COMMISSIONER DOMZALSKI: Absolutely not.

The health centers have always been known to be free healthcare centers, and I'm glad that since I was a child they were there for especially people in neighborhoods, especially the poor. Is there any anything that's going to change in the services that provide that moves it from free to some kind of cost to the public? COMMISSIONER DOMZALSKI: Most centers of our type do have a fee schedule.

Is that new? COMMISSIONER DOMZALSKI: Well, we're not contemplating a fee schedule at this 55 04/21/04 - WHOLE - BILL 040255 moment. We've been advised that we ought to think about that because there are people who -- first of all, we will never want to have anyone not to receive care because of a cost factor or inability to pay. We don't want to have that barrier in the health centers. So we've not taken that advice to introduce a sliding fee schedule for the uninsured. We haven't closed the books yet on understanding whether or not a service such as our pharmacy program whether it's possible to create a fee structure that would enable us to obtain some revenue but also keep the service available for those who just don't have any resources. We haven't finished that analysis yet, and that's one --

So there is a chance that because of the deficit, correct me if I'm wrong, that some of the services that you're providing at the healthcare centers, there's going to be fee required? COMMISSIONER DOMZALSKI: That's not on the table at this point. My budget is not balanced on any fee schedule at this time. 56 04/21/04 - WHOLE - BILL 040255

If the event that you would, you know, because of the deficit that you would have to go in that direction, have you studied what kind of impact that would have on the population that you serve? Healthcare centers, as I stated, have been traditionally a place where people that are poor go to. And if so, will you notify -- I think you would need to notify the public in advance. I would like you to notify us through the office of the President of any of the changes that will have such a dramatic affect on the population that you have served so well over the years. COMMISSIONER DOMZALSKI: At this time, there is no plan to implement in fee schedule in the health centers. The FY '05 Health Department budget is not balanced in any way in anticipation of any fees chargeable to patients. So the services will continue to be available to patients on the same basis that they are today. Having said that, I have got over 50 percent of the people who come into the health centers without insurance, I 57 04/21/04 - WHOLE - BILL 040255 have got in some of the health centers I have got as many as 55 percent of the children, children who are without insurance. Now, Councilman, 98 percent of the children in this City are insurance eligible. We need to do a better job in our system of getting all children insured. So we're not going to charge people a fee; that's not in the cards. But we do need to double our efforts and get everyone's cooperation to help us get as many of the insurables in our health centers on insurance, just because it makes good public policy and good public health policy.

And I agree with you. I concur with you. I think that is wise. And thinking ahead, this is an area that we can probably do better and be able to get reimbursement or get insurance for people that are needy, especially our children. Last week, I presented a resolution 22 that was adopted here unanimously by this body and was commending you and the Health Department for your tenacious work that led to Pennsylvania's Health Secretary, Mr. Johnson, 58 04/21/04 - WHOLE - BILL 040255 temporarily allowing Philadelphia to use a code of assist that maintains an HIV patient's anonymity. And I talked about that last year as I ran for public office of how important this was to me and to people that needed to protect their anonymity. Can you talk to us a little bit about the program and the impact that this health department has made inside the State of Pennsylvania? Again, I congratulate you for being able to have Pennsylvania relieve us a system that I think was unfair to our HIV community. COMMISSIONER DOMZALSKI: Thank you, Councilman Ramos. It was very generous and I very much appreciate the action of Council in this regard. But I have to quickly say that this was a collaborative effort and without everyone's participation, none of it would have been possible. The leadership here began with the Mayor. The Mayor was absolutely four square in front of not having names based reporting. Joe Cronaur was very much part of this. Ronda Goldfein and the AIDS Law 59 04/21/04 - WHOLE - BILL 040255 Project. We have Kevin Konar in the Action AIDS, and Jane Schull, a member of our Board of Health. There are just so many people and people at the grassroots that came out and said, "We support you in this." And that's not to say it wasn't a difficult process with the prior Administration in Harrisburg; it was a difficult process, and some of my colleagues understand how difficult that was. The fact that we've got the Secretary of Health, Secretary Johnson, understanding the needs of the community here in Philadelphia and understanding the barrier that names based reporting will present for people accessing needed testing, that was the basis on which he granted the year's waiver. Having said all that, what we're going to have is we've begun to implement this, we began to implement this the 31st of March. It will involve -- what everybody agrees is, first of all, we know a lot about AIDS. We know almost nothing about HIV. So we have to understand something about HIV disease and where it is in the community. So 60 04/21/04 - WHOLE - BILL 040255 what we're going to do here in Philadelphia is we're going to have reporting done by a code-based identifier. The code will consist probably some combination of maybe the last four digits of a social security number and perhaps some part of a birth date and so on as the code gets structured. So that when those reports are made, the government is not getting access to a specific individual's identity.

Thank you for your efforts and all the other community groups that fought so hard for this system to become a fair system for HIV patients. Madam Chair, am I okay to continue?

We're not being timed because there aren't that many year.

The issue of undocumented immigrants going to your health centers, how big is that population? How have you seen it grown? And what rights do they have, particularly undocumented immigrants, what kind of services are they entitled to in 61 04/21/04 - WHOLE - BILL 040255 your health centers? COMMISSIONER DOMZALSKI: They're entitled, Councilman Ramos, to a full range of health services that every other person is. One of the hallmarks of this Administration is we've reached out to the diverse communities that make up this wonderful City. Indeed, last night, we were with the Mayor in the Cambodian community at 16th and Washington. The Cambodian community is 10,000 strong in this City. And under the leadership of the Managing Director last October, we took a tour, all the department heads, to six or eight culturally and ethnically defined communities in this City. We have seen in the health centers increasingly new Philadelphians, immigrant population turning to our health centers in great numbers. The health centers that are most dramatically impacted would be Health Center 6 where about 40 percent of the individuals who access care in that center require some sort of language assistance as we go through. And that's pretty much across the board. They're 62 04/21/04 - WHOLE - BILL 040255 just two health centers where language services aren't needed as much across the board, and that would be Health Center in 5 Strawberry Mansion. But by and large, just about every health center requires -- we have some 23 languages that we need to provide interpreter services. If you go back 20 years, perhaps what we were looking at might have been two or three languages. So it's increasing, we're glad that people are coming to Philadelphia, we welcome them, and we're very grateful that we're able to provide a whole range of services to all communities, including the new Philadelphians.

So I'm an undocumented worker walking into Health Clinic No. 6, there is every service that is provided to a citizen is also available to that undocumented person? COMMISSIONER DOMZALSKI: Yes.

And we are sure that they're being attended to? COMMISSIONER DOMZALSKI: Yes. 63 04/21/04 - WHOLE - BILL 040255

I haven't heard any reports. I commend you for that. I haven't gotten any complaints that they've been turned around, but I would think that this population is increasing, making your local health centers that much more crucial. Because given the health crisis in our country, health center seems to be our only place for the have-nots to go to. So I'm glad that we're doing -- Are you satisfied also with the language translators and people that work in your centers and having enough in these centers to be able to take care of this immigrant population that is getting sick but still haven't become proficient in English? Are you satisfied with -- and if you're not, I need for you to tell us that. COMMISSIONER DOMZALSKI: Let me answer the last question first. I'm not satisfied, not with the language. We've made a lot the strides in that. We do employ interpreters in our health center. We do access interpreter services through a variety 64 04/21/04 - WHOLE - BILL 040255 of organizations such as Nationality Services Center. We translate, we use the language line. But, Councilman, all of those are substitutes and very poor substitutes for being able to have someone who has a medical problem be able to communicate information as personal as about your health status through a third party, and sometimes not all that ably as well. So there are many things we need to do. We are making huge strides. I know the Managing Director's leadership on this has been extremely useful because what we're going to be doing is being able to access the citywide contract on interpreter services. So that may increase our ability to interact with the limited-English-speaking community in the City. So I think we have done a lot and we've increased our services over the years, but to say that we are at perfection at this point or where we absolutely need to be or where we can be, I think we still have work to do. In terms of your first question, coming in, yes, the full range of services would be available to you. The only think I 65 04/21/04 - WHOLE - BILL 040255 would say as a caveat is if you were bringing your child with you and your child was insurance eligible, such as a child being born in the United States, we would ask you to cooperate with us and help you get insurance for your child. And often times that's where the rub is. Because as hard as we try, we still ask those questions on the forms like, "where do you live, who lives with you, how much income do you have and proof of income." And all of those things begin to get very off-putting to people who are here under a variety of statuses in the United States.

Are you saying that when your staff starts to question the parent of a child who now is eligible for some assistance, they don't want you to give you the information? COMMISSIONER DOMZALSKI: It's a little difficult. What we need to do is make sure we get our message across that the only thing we're interested in is getting an application for insurance, that this information is not going to government 66 04/21/04 - WHOLE - BILL 040255 agencies, it's not going to John Ashcroft, it's not going anyplace other than to the people who make a decision about whether or not your child is eligible for insurance and get your child the insurance that the child is eligible for which opens up a whole range of additional services which are very important for people to not only come to the United States but to stay and be successful in our country and in our City.

I appreciate very much what you're doing, providing service to a poor immigrant community, and what I see is an increasing number of that community of people that are undocumented. That's an issue that the country and the federal government doesn't seem to be giving us any direction of what to do in this area, and it's a degree of consternation among Americans and also a degree of unfairness going on with new immigrants into our country. Am I okay, Madam Chair?

If you don't mind, we do have -- 67 04/21/04 - WHOLE - BILL 040255

I'll do a second round.

Thank you. Councilwoman Miller.

Thank you, Madam Chair. Good morning, Health Department. COMMISSIONER DOMZALSKI: Good morning, Councilwoman. How are you?

Great. I have a couple questions pretty much around the issue of working uninsured and their need for healthcare. I believe a couple years ago we did talk about expanding the hours at the district health centers. What are the hours? Have they been expanded to evenings and/or Saturdays? COMMISSIONER DOMZALSKI: We do have expanded hours, Councilwoman. The normal workweek is 7:30, 8:00 to 5 or 5:30. All of our centers do have either an evening session or a Saturday session. And our Health Center at Broad and Lombard has two evening sessions, one on Monday evening and one on 68 04/21/04 - WHOLE - BILL 040255 Wednesday evening. That is something that's been a subject of some conversation in the past, several years in the department, because what we need to do is really look at our patient population and ask them what are right hours for you, for you to be able to access this service? Forever, we always provided services when it was convenient for us. So now we've got to get around to asking people, "What's convenient for you?" Because much has changed recently because since 1997, even people who are insured know or have some sort of assistance need to be in sort of educational program during the day or they're in jobs where they don't have the luxury of taking an afternoon or a whole day off to take their child for an immunization or to get well child checkup or even their hypertension checked for themselves. So I'm just very suspicious that our service structure in terms of the hours is adequate at this point. I just see, as we look over the months, that we look -- as we do 69 04/21/04 - WHOLE - BILL 040255 these patient surveys in the center, through some focus groups, and talk about what are the right hours. I' thinking we probably need more evening hours, but people may tell us, "Well, look, I'd rather not do the evening hours. Just give me a few more hours on Saturday when I can access it better. That's something that we're very much engaged with.

Okay. Because I do know that getting to doctors is important. And if the center is not assessable and open, then it does create a problem for people that need healthcare. What is the normal wait for prescription drugs? COMMISSIONER DOMZALSKI: I'm sorry, Councilwoman.

What is the normal waiting period to get a prescription filled? COMMISSIONER DOMZALSKI: The normal waiting period for a prescription in this City is probably a couple of hours. In our health center system it's a couple of days, at best. 70 04/21/04 - WHOLE - BILL 040255 And there have been times, Councilwoman -- and I think you and I have talked about this -- that wait has been as long as eight days and sometimes even longer in our health centers. That's why we've got to grapple with this pharmacy issue.

It does seem to me that the pharmacy setup is a real issue. I know in District Health Center No. 9, the space is an issue, which I think would impact the ability to effectively service people. I visited there, and prescription drugs were everywhere. They were everywhere, just stacked up on top of each other. COMMISSIONER DOMZALSKI: That's something that -- because you know what you're looking at, almost nobody else sees. We see the line outside the center. We see the patients who are in the line waiting to be told, "yes, come back in two days or four days." But when you look beyond there, some of the hardest working people in this government, Councilwoman, are the people who work behind those counters. The pharmacists 71 04/21/04 - WHOLE - BILL 040255 and those pharmacy technicians and the wide range of staff in our health centers, but when you look in there, the physical plant was never made for this volume. It looks like -- it's just is a jumble in there; you're right.

It's very small. And I know if you can't get organized, you can't really service people in an efficient manner. I'll talk to you later about what was discussed at the Germantown site just in terms of the ability to expand that would give them more space, and we can talk that at some other time. One thing I'd like to know, how does our infant mortality rates compare with other cities in the United States and nationally? COMMISSIONER DOMZALSKI: Well, it's similar to other large urban areas. And I'm kind of responding tentatively because there's a difference. It depends on where you look. And, unfortunately -- this is a part of a conversation I always have a lot of difficulty with. And we in Philadelphia count every 72 04/21/04 - WHOLE - BILL 040255 child that's born who dies as an infant death. That isn't the way infant mortality is calculated everywhere else. There's no 5 consistency. We looked at a place, for example, in one of the boroughs of the New York. 4. Well, I was astounded, because the population was very similar demographically to ours. One of the issues that comes up is that they don't issue a death certificate for very pre-term births. And so they've essentially calculated their way into a different infant mortality. I'm very reluctant to do that. What we need to do is focus on across the board getting our infant mortality rate -- see, if we had that map up there, Councilwoman, you're going to ask me -- and I think rightfully so -- is how come up in the Northeast and how come way, way up in the Northwest we've got an infant mortality rate of two or three, and in 73 04/21/04 - WHOLE - BILL 040255 parts of where I live in zip code 19144 and parts of Mantua in Councilwoman Tasco district, how come it's 15; twice, three times the percentage? And that's what we need to get at. And that's the issue we still have, babies being born too soon and too little. The other piece of this -- and I figured I'd try work this in, but there's something that gets me on the edge of my chair when I start looking at some of this stuff. It's not all that simple. There's a lot of different things that come together that impact infant mortality. And if you start teasing them out, you start to look at them. We know, for example, if we were to reduce smoking among pregnant women, we could reduce the infant mortality rate by as much as 30 percent. That's big. I had a meeting earlier this week when we were looking at tobacco sales to minors in this City. It's illegal to sell cigarettes to children in this City. It is illegal. We just looked at our enforcement, and two areas of the City that stand out. You 74 04/21/04 - WHOLE - BILL 040255 have 51 percent of the stores in North Philadelphia selling cigarettes to children. That doesn't happen in the far Northeast. It doesn't Chestnut Hill, it doesn't happen in Center City. That's the differences. And we've got to look at what our enforcement issues are there and we've got to bring this issue home to the people who are selling these cigarettes to kids. Kids can't afford a pack of cigarettes anymore. So these merchants will accommodate them because they'll open that pack up and they'll sell them two or three cigarettes at a time. We also know the impact of that because what happens is, particularly the women that we have in our smoking cessation programs, all of them -- almost 90 percent say they began when they were children to smoke. We've got to get our arms around that. I'm committing to support that effort and to be able to come in here and not wait until wait until next year but to be able to come within the next, say, 90 days, 6 months, to have a different turnaround on this 75 04/21/04 - WHOLE - BILL 040255 enforcement. We just met with Bob Sovibile and Dominic Verde about enforcement, ratcheting up this enforcement across the City.

We've also got to work with the State, because you take away a tobacco license, they can turn around and pick up another one because a tobacco license cost a grand total of $25 in this Commonwealth. It's a state issue. So we've got a lot of work to do across the board. And it's not about making life difficult for merchants; it's the law you shouldn't sell cigarettes and it's a good public health reason for not selling cigarettes to children.

Well, you know, there are stores out in neighborhoods that we all know of that will sell a loose cigarette. And I think part of what we have to do just as citizens is to report these stores. Once we report them, who do we report them to and how does L&I fit into this? COMMISSIONER DOMZALSKI: We have that number.

Before I came 76 04/21/04 - WHOLE - BILL 040255 to Council, there was a store a couple doors away from my office that was selling loss cigarettes and I just went over there and threatened to expose them.

It is L&I that we would report that complaint to. COMMISSIONER DOMZALSKI: Actually it's a 877 -- it's an 800 number.

You don't have to be so concern about the number. We're asking about the department. It's L&I. COMMISSIONER DOMZALSKI: Well, that could come into our tobacco enforcement. Certainly, it can get called into L&I, but we have a number in our department as well that --

Well, the Councilwoman's question is, who should she call? Should she call L&I or the Health Department? COMMISSIONER DOMZALSKI: Here is the number. It's 1-877-99-SMOKE.

That's part of what we can do when we're out meeting with 77 04/21/04 - WHOLE - BILL 040255 community groups, you know to educate the public and let people know, block captains know, et cetera, that this is what they need to do because we may want to let people know how smoking impacts infant mortality rate here in Philadelphia. What else are we doing? What groups are being funded to address the infant mortality issue in Philadelphia, particularly in zip code 19144 and also Councilwoman Tasco's zip code, 38 -- we share 38 -- that has the higher rates? COMMISSIONER DOMZALSKI: Well, what we're doing is we've created under our Title 5 Program in maternal, child and family health, a program called SAFE, S-A-F-E. It's an acronym for Services to Assist Families Excel. And this is focussing on children birth to 3 years of age. And what we've done is a RFP with this. In the Northwest area, we are re-doing that RFP. We were concerned that we didn't get enough bids, and we were concerned that the people who did bid on that, that they could have maybe didn't tell us everything 78 04/21/04 - WHOLE - BILL 040255 that they could have told us about all their services and so we might have missed an opportunity to do some business with them. So over the next 90 days that process will be completed, and we'll have a new or a continuation vendor in that area.

Okay. Commissioner, speaking of bids, I'd like to know -- and if you don't have it today, it's fine; we can get this information to the Chair. Of all the professional service contracts that the Health Department gives out, I'd like to get information on the number of minority firms that have received those contracts, the dollar amount of the total contracts, and the percentages of those contracts in terms of dollar amounts too of minority providers that have received contracts through the Health Department. COMMISSIONER DOMZALSKI: I can tell you this morning, Councilwoman, that in Fiscal Year '03, 23 percent of our contracts went to minorities. This year we're expecting that that will be 24 percent, and we expect that 79 04/21/04 - WHOLE - BILL 040255 our projection for FY '05 for is for that percent to go to 25. Now, the dollar amount I don't have, but I will get that to Council President right away.

All right. Thank you. Thank you, Madam President.

Thank you. The Chair recognizes Councilwoman Brown.

Thank you, Madam President. Good morning. COMMISSIONER DOMZALSKI: Good morning, Councilwoman.

Let me speak to the issue of the MomMobile. Could you give me an update, if you will, on the MomMobile and what lies ahead for the MomMobile in the next fiscal year? Let's start there. COMMISSIONER DOMZALSKI: The update on the MomMobile is probably a little easier than the future. And I promised I would go into only as much detail as people wanted to 80 04/21/04 - WHOLE - BILL 040255 have.

I appreciate the detail. COMMISSIONER DOMZALSKI: Where we are at this point with the MomMobile services, in the far Northeast at Health Center 10, we do have them in Strawberry Mansion and we do have a Latino Mon-mobile that's operating.

How many total? COMMISSIONER DOMZALSKI: I'm sorry?

Currently, how many? COMMISSIONER DOMZALSKI: How many MomMobiles? Somebody, before I'm finished, will give me that exact number. In terms of the way we're looking at services across the board, our issue with services around infant mortality is that we buy services that we think support our public health program objectives. It used to be that we would have organizations come to us and say, you know, "I've got a great program. I want you to fund it." It may not have had any 81 04/21/04 - WHOLE - BILL 040255 -- you know, we might not have thought, gee, that fits in service structure. It may or may not have. But in any event, we funded it. What we're doing is a lot differently than that. What we're doing is buying services that allow us to focus on the issue of infant mortality from the standpoint of getting women into prenatal care. And one of the issues there is the structured approach to how you are going to go and access women in the community who may need prenatal care. And that's a lot you different than taking care of women who are already in the system. There may be some overlap there, but it's a new structure in terms of the way we are buying services and the way we are evaluating proposals on how we go forward. I just happen to think that the concept of the MomMobile being community based and there is very good. The issue is, how many women do we actually identify and get into prenatal care. You know, one of the things we haven't talked about -- I just looked at a 82 04/21/04 - WHOLE - BILL 040255 figure in terms of prenatal care and women who need care. In the past year, we have had 373 births to women under the age of 15.

I'll hold my breath. Is that an increase or what? COMMISSIONER DOMZALSKI: That is a slight increase because I used to use a figure before of about something less than the 200s on that. That's a change. If we look at the figure of women under the age of 18, we're still looking at close to 3,000 births. So there are women out there we really do need to find ways in which we can interact with young women, get then involved, get them involved in prevention services, get them involved in a who variety of programs and services. So I'm not saying for a minute that the MomMobile and the concept isn't a valuable one. What I am saying is that what we need to do is look to see how that either as it now exists or how it can be modified can fit into our overall assault on infant mortality.

The principal 83 04/21/04 - WHOLE - BILL 040255 purpose of the MomMobile is to outreach and identify young ladies and women for prenatal services. So agree in principle that it's meeting its mission? COMMISSIONER DOMZALSKI: Absolutely. I agree that is an important mission.

Are there tools in place to track young ladies that come into the system by way of the MomMobile to further justify its purpose? COMMISSIONER DOMZALSKI: Yes, we do look at the number of women who are brought into care and were referred into services, number of contacts and that nature. We can supply that program data to you, Councilwoman.

So you would be able to say of the 378 women, an approximate number of those that were tapped or touched by the MomMobile? COMMISSIONER DOMZALSKI: Or not.

You can make that connect? COMMISSIONER DOMZALSKI: Yes.

Have you been 84 04/21/04 - WHOLE - BILL 040255 able to determine how many MomMobiles are currently within the Department? COMMISSIONER DOMZALSKI: We are funding all or in part four MomMobiles.

Currently funding four? And you say you now buy services from others who provide a similar service? COMMISSIONER DOMZALSKI: When we're looking at the whole business of infant mortality, we have several ways that we approach this in the City. These are new in compared to, for example, the service of the MomMobile. The MomMobile service is an important one. What we also do is we have the David Olds project --

You have the what? COMMISSIONER DOMZALSKI: David Olds.

Okay. COMMISSIONER DOMZALSKI: You know, it would be nice if infant mortality were straightforward that we could say, you know, this approach if we do X, we'll have Y result 85 04/21/04 - WHOLE - BILL 040255 and infant mortality go down. But it's a complex phenomenon. And what we need to do is learn an awful lot about why babies are dying before the first year of life. And some of those things we're learning through the David Olds Project, which is a very intensive program that's operating in West Philadelphia and it's for first-time mothers and we have -- the capacity of the system is 400, 400 women in the system under the David Olds. And what we do is look to see what interventions occur and what are successful in getting women into care. And also in that what's is called the conception phase, which is the period of time between the end of one pregnancy and the beginning of another and what impact these services have had with regard to that. So we're learning things from the David Olds Program.

Make the connect for me between the David Olds Project and MomMobile. COMMISSIONER DOMZALSKI: There's no 25 comparison. These are intensive -- the David 86 04/21/04 - WHOLE - BILL 040255 Olds program is nurse-based. We have one nurse that will have families. Nurses 4 receive very intensive specific training 5 according to protocols that have been 6 developed by Dr. Olds, and there's a very 7 stringent evaluation process in terms of the 8 educational piece. 9 A MomMobile, while not exclusively, 10 is an outreach service. And they also provide 11 a number of services inside our health centers 12 to women who are already in the our health 13 centers. So not to say that those services 14 aren't absolutely important, but it's a piece 15 that we need to evaluate in terms of where 16 we're going now with our assault on infant 17 mortality. 18 The other piece is something that we 19 just got started and our Division of Maternal 20 and Child and Family Health and our Medical 21 Director Dr. Godley heading this up called the 22 FIMR, F-I-M-R. It's called Fetal Infant 23 Mortality Review. This is sort of the area 24 where we're going to learn a lot more about 25 what happens in those first few days of life 87 04/21/04 - WHOLE - BILL 040255 that end before a year is up and the child dies. These are actually working with parents who have had a loss and accessing not only the social data, the demographic data, but also the clinical history, working with the hospitals. So we're going to learn an awful lot, and from that kind of learning --

Madam President is to give me the red bell in the minute. So is that to suggest then that FIMR is supplementing or complementing MomMobile services? COMMISSIONER DOMZALSKI: No. What it's going to do is it's going to give us information on which we might decide that we have some different programs that we may need to implement program either in the MomMobile mode or apart from that.

What does the future hold for the MomMobile? If you currently have four -- and I hear from you four; I get different numbers from others. What's the status of the MomMobile going forward? 88 04/21/04 - WHOLE - BILL 040255 COMMISSIONER DOMZALSKI: I think the future depends on what the success rate is of the MomMobile in doing the outreach to get women into prenatal care early. What is the success of that? And the more successful that is, the more successful that is, the more secure the future of that mode of service delivery. We may still have things going around called the MomMobile, but we may be doing something a little bit differently.

So internally then you have a department or a practice or procedure that allows you and your staff to do a self-assessment on its success, correct?

Yes.

Today, as we know it, there are four. And at what juncture do you see making a determination or at what point do you se yourself giving the Department an evaluation around the MomMobile to further determine its life in the future? COMMISSIONER DOMZALSKI: Well, that's what's going on right now, in terms of some of this. I think there may be some 89 04/21/04 - WHOLE - BILL 040255 MomMobile activity that is suggested for the Northwest part of the City in the area that we're now competing for the Safe Program. There may be some activity associated with that. What we'll be doing is looking at either those proposals and looking at what services are now being provided and actually looking at the success rate of the current activity in bringing pregnant women into prenatal care and keeping them in care.

Did you have a follow-up question, Councilwoman Tasco?

She's been waiting.

Past my five minutes, right?

Way past it. So if you don't mind, Councilwoman, we'll have a second go-around.

I'll wait for the next round.

The Chair recognizes Councilman Clarke. 90 04/21/04 - WHOLE - BILL 040255

Thank you, Madam President. Good morning. COMMISSIONER DOMZALSKI: Good morning.

Commissioner, a couple questions. Recently, as the part of the redistricting, I picked up a section of the City that has a substantial amount of industrial sites, some of them closed, over in Fishtown and Kensington. And as a result of that, I've had to attend numerous meetings to deal with certain environmental issues. The Absco site is one of them, the more notorious sites. I need to get some clarity on the lines of responsibility and jurisdiction as it relates to the municipal remediation unit, the state and the federal and who has jurisdiction, who dictates what strategies will be implemented to resolve some of these issues. The other question I have is about aggressive dogs as it relates to the City taking over the responsibility of the SPCA and 91 04/21/04 - WHOLE - BILL 040255 the reason why the SPCA got out of the dog business. But if you can talk to me about the environmental issues, the staffing levels on the City level, the ability to adequately respond to some of the concerns that are raised. COMMISSIONER DOMZALSKI: I will, Councilman. On the abandoned industrial sites, there are a number of agencies involved with that. The way we handle things in the Health Department is that typically we'll get a call from someone about a site, there's a leaking drum or whatever. We'll respond to that and do an evaluation. Frequently, what we'll need to do is pull in maybe an L&I unit from the commercial and industrial unit in L&I. Maybe there's a citation that belongs there. It may be the kind of product involved that's got federal regulations associated with it. For example, if there's asbestos involved, that may implicate the NESHAP (ph) regulations that are federal and come out of EPA. What we'll do is make sure we pull those 92 04/21/04 - WHOLE - BILL 040255 agencies in together and we may, in fact, not be the lead after that investigation goes forward. There may be a federal citation given to the company.

Are you saying that there could potentially be different regs associated with different types of environmental issues? COMMISSIONER DOMZALSKI: I am.

Does the municipal level have some whereas we may say that this particular company is in violation of an act on a municipal level but not necessarily on a federal level? COMMISSIONER DOMZALSKI: Right.

Why is that? Why would we have -- COMMISSIONER DOMZALSKI: We can do a lot under the Health Code. For example, we can declare something, based on fact and assessment, a public health issue and we can issue an order. The orders -- and we're looking at our whole order system at this point and the fines that are involved. Often 93 04/21/04 - WHOLE - BILL 040255 times at the municipal level, the fines are not sufficiently high enough to be an incentive to impact clean-up. At the federal or state level --

Cost of doing business basically for a person. COMMISSIONER DOMZALSKI: Precisely. That's different at the state level and it's sure different at the federal level. What we like to do -- and I know this is the approach you've taken particularly in one of those sites that you mentions, we want to problem resolved. We want the problem cleaned up. We want it made safe. We want it remediated. Sometimes when the remediation happens, sometimes we'll end up with a lot of the responsibility, particularly if there's reuse involved. We had one site in one part of the City, it was going to be reused as a fast food facility. And the previous use of the site was a dry cleaning operation in which dry cleaning fluid had seeped into the soil. That needed to be remediated. We needed to -- 94 04/21/04 - WHOLE - BILL 040255 under our federal delegation, we needed to oversee that and look at what kind of remediation the company was proposing, do an analysis in terms of personal and public health impact and then supervise that until it was completed. So it varies, but our role there, I think, is to, for example, work with whoever brings us the issue or one that we find on our own, to get it to the proper level of government to get the result that everybody wants, which is a remediation, and a permanent one, of the condition.

Is there a reason why -- you may not be able to answer this question at this time. Is there a reason why we don't have uniform codes as it relates to the violations? Recently, I know in the Building Code there was an Act, a Uniformity Act in the Building Code that we have uniform codes associated with certain levels of construction. And I would think that something as serious as the environmental 95 04/21/04 - WHOLE - BILL 040255 health of our citizens that we would get together and have sort of universal code, minimally at the state level but preferable at the level also to give us the broadest ability to make sure we remediate these problems. The other issue is, have we looked at possibly raising the cost of the fines? COMMISSIONER DOMZALSKI: There's a proposal that is being pulled together. We just contributed some information to the Managing Director about what current fine levels are, what penalties are, and what we think about those in terms of their usefulness. In all cases, I think we agree they ought to be raised. In terms of the uniformity of the Code, a lot of the stuff we get involved in has public health implications, really the resolution of that requires the enforcement of the Property Management Code, and that's usually L&I, so we'll work in conjunction with them. Rather than develop our own code about how a property maintain ought to be maintained or avoid a public health nuisance, that 96 04/21/04 - WHOLE - BILL 040255 usually the way the Property Management Code is structure, there's usually a solution within that code. So we use that as well as some parts of the Plumbing Code to address those issues. But we'd be happy to talk about some more of that.

You didn't really ask my question. I'm not suggesting that's your responsibility to pull all of the pertinent parties together, but it seems to make sense to me that you would want to have a uniform code to give you the ability to impact broadest way. And I don't know should the federal government be responsible for initiating that process. If there's some things on the federal level that you do not currently have in your Code and you have to get federal government involved, wouldn't it make more sense to simply adopt that particular code to give you the broadest ability to impact on environmental issues as opposed to having to bring the feds in? Why don't we just change our regs to reflect all of the various code violations as it relates 97 04/21/04 - WHOLE - BILL 040255 to environmental concerns? COMMISSIONER DOMZALSKI: I think that does make sense as long as we could get the same penalty level that would be. To the extent that penalty is going to be an incentive to getting the resolution we want.

Why don't we do that? I'm assuming that the penalty phase, that the money would go to the City as opposed to going to the Feds. COMMISSIONER DOMZALSKI: Who knows how that might come out, because when that bill comes over here to change those fees or those penalties, I think the maximum penalty we have is something like 300. I think the maximum federal thing can be something like 10,000 a day for every day of the violation. So it's huge. I don't know if there are municipal code legal aspects about that, about why we can't be that stringent, but we'd be happy to talk to you about that and work with you on that.

And not just the increase but also the ability to have 98 04/21/04 - WHOLE - BILL 040255 additional code enforcement issues on the table because if the federal level have certain code violations, I'm assuming that if they impose those code violations, that money goes to the Feds. Why don't we adopt those code violation so then the penalty and the fine would go to the municipality as opposed to going to the Feds? You understand where I'm going? COMMISSIONER DOMZALSKI: Right. And to some extent we've done that with some of the air management stuff. What we've done as part -- we have three laws that we enforce. We have the local air pollution control, the State Air Pollution Act and we have the Federal Clean Air Act. And in our plan, what we've done is incorporated those into our plan so we essentially do have a uniform code enforcement in that regard. I'm a little something reluctant to say that that would address something like the ABSCO issue.

I mention that in particular because I'm in the midst of it 99 04/21/04 - WHOLE - BILL 040255 and it's extremely frustrating when you have these different arms of government at a community meeting and you don't know who to hold responsible and different answers from different people. If we simply had the same code as the federal government, which I'm assuming is the broadest one out there, then we would have to have all of these other people involved. We can impact on that environmental problem ourselves. Before my time runs out, on the aggressive dog issue, in the hearings that we had a couple years ago, the SPCA essentially said they were getting out of the dog business primarily because of pitbulls and rottweilers, and they primarily felt that there were an entity that was being used to go out and get these dogs and put them to sleep because there was no likelihood of adoption or anything. And they asked us to impose essentially a ban on certain aggressive dogs. Now that the City has taken that responsibility, what is the position of the City? And I mention this because we've had 100 04/21/04 - WHOLE - BILL 040255 a recent spat of injuries, some to children, as a result of these aggressive dogs. What's our position on that now? COMMISSIONER DOMZALSKI: The way we got into this with the SPCA, the SPCA I think took the position that they ought to be banned, there ought to be dogs that ought to be banned, but I think in general -- and this is in general, that it's not so much the breed as the way the animal is handled and the way the animal is cared for and that there can be pitbulls that are very docile and very loving pets. Unfortunately, what we see are the situations where that is not the case and where there are injuries and sometimes the injuries are extraordinarily severe. I'll tell you at this point there are times when I see those injuries that I understand -- there ought to be some way to be able to predict this to be able to put controls over this. We do have -- but it's usually after the fact. It's usually after the fact where we can actually go to court an have a judge to declare an animal a vicious 101 04/21/04 - WHOLE - BILL 040255 dog. In order for that owner to retain that dog, a number of things have to be in place such as a huge fence and certain controls and all the rest of it. And we get the responsibility of going out and monitoring whether or not those protections are in place. And if they're not, the judge will amend the order and the dog will be put to sleep. So a way around about whether or not these breeds ought to be banned wholesale in the first place. There's a lot of discussion on both sides of that issue.

I actually think they need to be banned, frankly speaking. So you're suggesting that that short of that, if we can show just cause that a level of security can be imposed on individuals who have these dogs as pets or weapons or whatever you want to them, that's a possibility as it relates to the legal aspect of it? COMMISSIONER DOMZALSKI: Absolutely.

I live in a community where a lot of pitbulls -- and I hope nobody's waiting for me tonight when I 102 04/21/04 - WHOLE - BILL 040255 get home. But this is a serious issue. Unfortunately, a lot of people -- and I think the majority of people get these dogs, they use them as weapons or for purpose of fighting. And I just think that at some point we've got to take a stance on this. COMMISSIONER DOMZALSKI: Before we get to that second level, which some point we may need to get to, is that whoever is concerned, neighbors or whatever, give us a call, and what we'll do is send out an investigator to assess that situation. And we'll keep coming back just to see what's going in that neighborhood and we'll be able to issue a notice to the owner. And if we do see a serious situation where there is threatening behavior, if the owner doesn't comply with that, then we can take it to the next level which would be to court.

Thank you. I think my time is up.

Thank you. The Chair recognizes Councilwoman Tasco. 103 04/21/04 - WHOLE - BILL 040255

Thank you. Commissioner, I want to follow-up on Councilwoman Donna Miller's request for information. You see all these people in the room today. Most of these people are here today because are concerned about the disparity in funding from the Health Department to community-based organizations. As I look through the budget and see some of the providers here, it seems to be that most of the providers are very large organizations and that the smaller neighborhood groups that in the past have always provided community outreach for whatever reason are not getting the level of funding. So I want to know in the information you provide, whether they are minority or small, how many community-based are receiving funding for service to the community and what is the dollar level. COMMISSIONER DOMZALSKI: Absolutely. We'll do that.

Because in the last couple of years, many of the groups have expressed concern about the lack to the 104 04/21/04 - WHOLE - BILL 040255 ability to access funds from the health Department. And when they submit their proposals, they're not given. And we've submitted proposals to you on behalf of organizations, and for some reason there is an excuse not to fund them. So we want to know what the process is. And in that line, I want to know who in the Health Department -- what is your policy of determining what programs will be developed, what programs will be funded? How do you determine what programs will be funded, where they will be funded and on what information do you base it? Is it just done by whatever department you have that goes out and gets a grants, or is there an internal process where you sit down and talk about policy? I want a short answer about policy and how we're going to provide services. Because we have in the Northwest -- I've constantly talked to you when this whole issues of infant mortality came out that the highest level in the newspaper reported was in the Ogontz section. I don't know yet -- and that was about three years ago we had public 105 04/21/04 - WHOLE - BILL 040255 hearing on the issue. I don't if your department has come up with anything to address the issue up there. I want to know how you plan to do that, if you plan to do that. And if it's not the way you operate, do the community groups decide, well, we need to do a program, let's go to the Health Department? Or the Health Department sees a need or a vacuum and says, there has to be something there? How do we do it? How do set the policy to address the health issues? COMMISSIONER DOMZALSKI: It is based on need.

Well, the need as established by your Department and by the need that we've established in the hearings on infant mortality, what are you doing about infant mortality in the Northwest? And if you're talking about cutting out the MomMobile in the northwest, what services do you get? You talk your Safe Program. There were two groups that responded to the RFP. You're saying you don't like the groups, 106 04/21/04 - WHOLE - BILL 040255 you're going to bid the RFP. I want to know why. COMMISSIONER DOMZALSKI: It's not that we don't like the group. There's a lot in your question, Councilwoman. I can tell you -- and we'd be happy to do a separate session on this. But just briefly, when we looked at what the need is, that's why we have maps that show that the infant mortality in your district higher than in some of the other districts. So we know there's a need there. Two, what should be done? And that question there is what should be done. Should what be done, should the service that's provided be determined that we need to interface better with teams, those kinds of things for a whole variety of pieces to that, we pretty much determined through our maternal infant care program the kinds of services that we think have the biggest probability of impacting in that neighborhood. Then the question is who can best provide them.

Who makes that decision? Who determines that need? Who is 107 04/21/04 - WHOLE - BILL 040255 at table? COMMISSIONER DOMZALSKI: At the table would be our Director of Division of Maternal and Child Health, Dr. Ingert that heads up our OB program, Dr. James. Depending on the issue, Dr. Godley might be involved and some of our social work staff as well to look and to say, okay, these look like the interventions that make sense for that particular issue in that particular neighborhood; who in the neighborhood is best able to provide those services. And what we want to do is drive those services down to the neighborhood level; absolutely in the neighborhood at the neighborhood level. And to do that, we want to have organizations help us who are comfortable who know how to interact with the community, know how to deliver culturally appropriate, competent services in the neighborhood to get the effect that our program individuals identify as having the highest probability of impacting on something as complex as infant mortality. And then we 108 04/21/04 - WHOLE - BILL 040255 make a decision to award it in the first place. Often times, the next step that happens is where we get into a lot of trouble, and that's because we've started to evaluate what is being produced in term of outcome. We used to measure, for example, immunization on how many times you knocked on the door. We're not interested in that anymore. We're interested in how many times you've brought a child in to get immunization. That's different than knocking on the door. I might have to knock on the door to do it, but we're interesting in measuring how many children you actually bring in who will end up being immunized. That's the outcome. And often times, what we have to do is to adjust our programs. And we never in any circumstance have a situation where there's a performance with a contractor, a contract agency, where we say, "You didn't do it; we're not going to contract with you anymore." We always tell --

We just went 109 04/21/04 - WHOLE - BILL 040255 through that with Maternity Care Coalition on the immunization, where they just took the money away from them. They were doing it in the Northwest. And I asked what basis did you take away that money and give it to somebody else or say that you were going to have someone else provide the service. I never got the answer. I never got documentation. Nobody could ever document why that money was taken from the Northwest. COMMISSIONER DOMZALSKI: Councilwoman, I was prepared to give it to you then, I'm prepared to give it to you now. And whenever we can get into talk, we'll sit down and go over it.

But who's doing the program? And you talk about the neighborhood and the sensitivity of the people in the neighborhood. And the group that I heard that got the program, I'm not sure that they're more connected to that community than the group that was doing it. COMMISSIONER DOMZALSKI: That's why 110 04/21/04 - WHOLE - BILL 040255 I'd like to share that information with you.

And no one told them that they weren't going to get the money. You just took the money and never told them they were going to take the money away from them. So I want to know who's making decisions. I want to know who made the decision on the Safe bid. Why if two providers -- I fussed with Maternity Health Coalition for years about expanding their program. They expanded to the Northwest. We don't have a lot of community groups up there that you may have in some other parts of the City. So when we get an organization that has a history who can -- and La Salle College has provided health services throughout. They have a health clinic over in Hillcreek, and you just snatched the program away from them. So you're not going to get anybody else up there to do the program because there are no 22 other community-based programs up there. I want to know who is making the decision and who's evaluating the success. COMMISSIONER DOMZALSKI: Well, on 111 04/21/04 - WHOLE - BILL 040255 the Safe piece, you see, I can give you this piece of information but it won't be responsive to the next piece of it. Who makes the decision on the Safe Program is a group of people that are some individuals from the Health Department, some individuals from some of the schools of nursing. I can give you that, but it takes a little bit of detail to go into that and that's why I think it's worth me sitting down as long as half hour and going over it.

We have some concern about who makes the decision in the Health Department and what basis they make those decisions. COMMISSIONER DOMZALSKI: I'd be happy to share that with you.

You don't want to talk about it right now, do you? So we'll talk it with the Maternity Health Coalition, because there's a problem there in the Health Department in terms of who makes the decisions for what community and what groups get the money and what groups don't get the money. 112 04/21/04 - WHOLE - BILL 040255 COMMISSIONER DOMZALSKI: I guess, Councilwoman, when it comes right down to it in terms of the final decision, I make it.

Well, then you're not making a very good decision. You're not making very good decisions. I'm told that the Coalition was told that they were not going to get the money for the Northwest for the MomMobile, but it's here in the budget. Now, are they going to get the same level of funding that they got this year? COMMISSIONER DOMZALSKI: I don't know. I don't know if they are going to get the same level of funding. The reason is that we're looking and we've competed all of the services for competitive bidding --

But you have no 19 one else doing services in the Northwest. You have no one else doing the services in the Northwest. You may have competing groups in West Philly. But if a group that has history wants to provide the service, who in the department decides they shouldn't do that? 113 04/21/04 - WHOLE - BILL 040255 All we want, bottom line, are some services for the people who are dying. Their babies are dying in the Ogontz section. For three years we've been talking about it, but there has been no action out of the Health Department to address the issue. COMMISSIONER DOMZALSKI: There has. Councilwoman, there's been action. We pick that area to institute the FIMR Program. I would really like an opportunity to sit down and talk about this in some detail. I think that when we do, we will have more information. And we still may have areas of legitimate disagreement, but I think we really need to share that information.

Let me go back to the health centers. Councilman Ramos asked you about a fee. How is the billing in the health centers for constituents who qualify for medical assistance and what do the centers do to ensure that the application process is completed? COMMISSIONER DOMZALSKI: What we've done is -- we used to refer people to the 114 04/21/04 - WHOLE - BILL 040255 county assistance office to make applications. We knew that wasn't working. So what we've done is put insurance counselors and social workers in all of our health centers to take applications right on the spot to help people understand what insurances they might be eligible for and to assist them with the application process as we go forward. And we don't wait to deliver care until the application approved. We deliver the care while the application is in process.

So what is the success rate of that process. COMMISSIONER DOMZALSKI: Well, when we started it, we had 64 percent of people coming to the health centers who were uninsured. We expect that this year that's going to be down to 55. It's down to 60 percent now. By the end of this fiscal year, we expect that that's down to be down to 55 percent. And by the end of the new fiscal year coming up, we expect that to be at 50 percent.

I've met with a 115 04/21/04 - WHOLE - BILL 040255 gentleman you know, Bob Brand, who the Council President and some of us in Council have met with him, look at this accessing system they have to retrieve -- you've got a client into the health center, and through this program they can go online and access not only Medicare services, but all other LIHEAP services, all other services that would help the City capture a lot of dollars, it would help PGW. You've got a client there, they qualify for services that -- not just health insurance, but other services that would help the City with its fiscal problems. What is your assessment of that? I know he messed with you. What do you think of that process? COMMISSIONER DOMZALSKI: Actually, not only did Bob come over and meet with me, but I was so intrigued with what he had to say that I asked him could I come to meet with him in his office and actually see that program in operation. And we spent a good afternoon one Friday afternoon there, and it was quite impressive. They do have an excellent 116 04/21/04 - WHOLE - BILL 040255 database. And for people in our health centers, we know that by and large our patients and perspective patients qualified for either medical assistance. They sometimes qualify for PACE, a prescription assistance program for the elderly. They sometimes qualify for CHIP, the Children's Health Insurance Program. So our challenge is to identify. Once we've identified that, we pretty much know that from our insurance counselors, is to get that application process started.

Well, what's wrong with his process? I mean, it's user friendly. You capture a lot of information. It would save the City a lot of money. And it's been implemented in a lot of offices. There's some state representatives that are going to put it in their offices that will help not just the City but also the client. Don't. You see it as a valuable asset to your department? 117 04/21/04 - WHOLE - BILL 040255 COMMISSIONER DOMZALSKI: Well, actually, I think where we had our most discussion was around PACE and how --

I'm talking about all services. They can access all services. Certainly, help you capture your medical assistance payment. You can tell them they qualify for CHIP. They can get LIHEAP services. They can qualify for all the services just by plugging in their name into a software program. What is so difficult about that? COMMISSIONER DOMZALSKI: Well, what's difficult about it is -- and it's not difficult, it's very easy. As you identify what the service is that the person qualifies for, the hard part is getting the application done and getting it through their approval process. So that doesn't mean what Bob has to offer isn't valuable. And I'd be happy to have Bob come in and talk to us again about some other issues or other services that he'd like us to know about. We did have a fairly lengthy discussion on PACE. 118 04/21/04 - WHOLE - BILL 040255

I'm sorry. I'm overwhelmed.

Is Rob Dubow in the room? I think he had met which of the gentleman you're -- I don't know that it's the same gentleman that you're referring to. Maybe Mr. Dubow could shed some light on this.

Rob Dubow, City's Budget Director. Yes, someone in my office did meet with Mr. Brand. And the next step for me was to actually talk to the Health Commissioner and get his impression on it. I haven't taken that step yet, but we did meet Mr. Brand.

What was your assessment in discussing it with Mr. Brand? Do you see it as a valuable service that could benefit the City?

It seemed on its surface that it was interesting. But, obviously, in any proposal, you need to understand the details. And that's why we wanted to circle back with the Health Department. 119 04/21/04 - WHOLE - BILL 040255

Well, when are you going to meet with the Health Department? Since we have such a massive deficit and we're getting ready to cut recreation centers, we're getting ready to cut out arts and culture. And there is a system that is used in other cities and counties to capture dollars, why we find it so difficult to think outside the box to move to accept something that's new and different that could be beneficial to us to capture money for this City?

I don't think we're resistant to it. We just want to understand it and make sure that we think it works. And if it's going to be something that would generate revenue for us, obviously we'd be interested in it.

We hope, Mr. Dubow, that you will move forward in doing that. Thank you very much. I'll come back.

The Chair recognizes Councilman Ramos. 120 04/21/04 - WHOLE - BILL 040255

Madam Chair, I yield to my colleague Blondell Reynolds Brown.

The Chair recognizes Councilwoman Brown.

I thank my colleague. I assured him I would not abuse this opportunity. I'm going to ask one question, leave and come back, because I have several. A follow-up to Councilwoman Marian Tasco's question, who we have to remember chairs Health and Human Services and is intimately involved with this issue of indigenous professionals who care about providing a service in a world where they live. Pulling from my experience with the Youth Services Coordinating Office, there was a planning unit and an evaluation unit. And I had a chance to work in both. In the planning unit which was responsible for going out and sitting with those who were providing services to children and youth, we had a process where we had to sit down on the front end of the RFP and 121 04/21/04 - WHOLE - BILL 040255 provide an orientation session to help them understand what the criteria would be for a particular proposal that was about to let. Is that a standard operating procedure in the Health Department? COMMISSIONER DOMZALSKI: Absolutely.

So before a proposal is let, the world is informed that this opportunity is coming and invites them to -- let's them know what the criteria are and invites them to apply? COMMISSIONER DOMZALSKI: Yes. After they get the RFP, if there are any questions about it, there's an opportunity to raise those questions at that point.

You mentioned on the back end that ultimately a decision is rendered. For those organizations that do not meet the criteria as outlined, what happens? COMMISSIONER DOMZALSKI: It depends. We'll have a discussion with the organizations talking about why their proposal wasn't competitive. Sometimes it's an issue -- we do this fairly extensively around some of our 122 04/21/04 - WHOLE - BILL 040255 AIDS RFPs with community-based organizations where some of the issues have to do with having the need for technical assistance or payroll management and those kinds of things.

Does the Department provide technical assistance to those agencies that want to -- COMMISSIONER DOMZALSKI: Yes, we do. Because what we're trying to buy is not necessarily -- the highest and best use of that community organization's time is frequently never whether or not whether they can keep books accurately, but it's more how they get out and access the community. And so what we do is sure up and provide technical assistance on the bookkeeping end so we can avail ourselves and, more importantly, have the community avail itself of the special expertise of that organization.

What about on the program end? COMMISSIONER DOMZALSKI: Program end, sometimes maybe it's a misunderstanding. Maybe we can adjust it on that end. Often 123 04/21/04 - WHOLE - BILL 040255 times, it could be a situation where people are saying, you know, "We understand that goal. You asked for this, but we don't understand -- you know, you ask for X; why isn't Y if it accomplishes the same end just useful to that." Sometimes we can make an accommodation. Sometimes if we make a change in the standard, we have to say, "Wait a minute. If we are going to change and maybe we should change that standard or that requirement, but in fairness we need to let everybody now bid against the new standard." So we may have to go out to re-bid on it.

Is there any tracking of agencies? A practice at the Cultural Fund is that we actually track arts and cultural organizations who don't meet the muster to see how many times they apply. And the goal is to move them to a place so that they can take benefit of those dollars. So is there tracking of agencies that don't meet the muster one, two or three 124 04/21/04 - WHOLE - BILL 040255 consecutive years to really get a handle around and make sure they clearly understand what the criteria are? COMMISSIONER DOMZALSKI: Yes, Councilwoman. And sometimes what we do is actually ask those organizations like that to partner with another organization for a period of time until they can get their ses legs kind of thing and up and running on their own. Sometimes what we'll do is just provide technical assistance from a technical assistance agency, an accounting firm or whatever directly. But that's an ongoing process.

Could you provide that kind of information to the Chair so that those of us on City Council can look at that more closely to what has happened over the past few years, particularly around agencies that apply, don't get the opportunity, still care and are interested, apply again and for varying reasons don't meet the muster so that we can figure out what we in the body can do to help them who are 125 04/21/04 - WHOLE - BILL 040255 indigenous to the world where they want to provide services right in their world because they live and breathe it every day? COMMISSIONER DOMZALSKI: I agree. Absolutely. We'll provide that.

Thank you. I'll yield back to my colleague Councilman Juan Ramos.

Councilman Ramos.

Thank you, Madam Chair. Mr. Commissioner, one of the few compliments that I get as I've gotten older about my physical appearance -- compliments are very, very few, and I usually get them from my family. But one of them that I'm very proud of is they say to me that I got healthy teeth. And I like to tell them probably the main reason why I have healthy teeth is because as a child the Health Department would come and actually escort the kids from my elementary school to Health Clinic No. 6 which was right across the street from the school. 126 04/21/04 - WHOLE - BILL 040255 And I know that those services are not out there the way they were back then, but dental care for children is the blueprint for healthy teeth for us when we get old. And I know that that program has been, you know -- it's not where it was at. But I do know that you have started to do some innovative stuff with Temple University. I know that Temple's dental school, you opened up a program in at least one of our schools, I believe the Clemente School in North Philadelphia. Are you going to be doing more of this? I think that this is something that we can probably get institutions like Temple and others to be able to provide this type of service, particularly to our kids that cannot afford -- their parents cannot afford to dentists. Dental care is very expensive nowadays. COMMISSIONER DOMZALSKI: Councilman, we need to do that and do more of it. The Roberto Clemente School is just wonderful. I think we did that last summer, opened it up. You were there for the opening and Dr. Ivan Lugo and Dean of the dental school at Temple. 127 04/21/04 - WHOLE - BILL 040255 We got some funding from the State. We got some support from Temple Dental School. It was just wonderful, a wonderful program. And the whole key is the importance of dental care for children. The period of time in the Department that you refer to is our focus was exclusively on children. We had a director of dental medicine that required all our administrators to know what the DMF was across their health center population, and that was the ratio among decayed teeth, missing teeth and filled teeth. There was a certain level where you wanted to get dental health for children at a certain level and keep it there. So important an issue such as infant mortality as well because there's some information that dental infections are important with regard to poor outcomes if there's dental infections for women who are pregnant. So it's important across the board. I will tell you that when you look at the profile of our health centers at this point, we are seeing more adults now in the health centers than we have before. That's 128 04/21/04 - WHOLE - BILL 040255 not to say that dental care for adults is not important, but the critical nature -- dental carries among children are the number one reason for missed school in this country, just across the board. So it's an issue that's on the table of the American Public Health Association, the American Dental Association, and something we have to pay more attention to here in our system about just, you know, do we have children to get in those chairs and are we making sure we try to get them in for early care.

I didn't see any of it in your report or your diagram of how you spend your money in the various programs. Do you see yourself doing more of this? Is this a plan more of this? And if so, are you doing it through your contract employees? Is that the way -- I believe that's the way you did at Clemente, right? COMMISSIONER DOMZALSKI: Yes.

Do you have any plans to do more of this? COMMISSIONER DOMZALSKI: Yes. That 129 04/21/04 - WHOLE - BILL 040255 was from a particular funding stream. What we need to do is look for --

Do you have any money left in that funding stream? COMMISSIONER DOMZALSKI: No. It's all spent and going down rapidly. And what we're looking is looking to keep that program going.

I would like to work with you on this one particular issue to the extent that I can. My doors are open to you. Thank you, Mr. Commissioner. Thank you, Madam President.

Thank you. The Chair recognizes Councilman Rizzo.

Thank you, Madam Chair. Commissioner, first of all thank you for your Department's response to my needs are always first class and very effective and I appreciate that because it's such a very important issue to me personally. 130 04/21/04 - WHOLE - BILL 040255 You may have addressed this, and I apologize, I had to leave the Chambers for a few minutes. An area that I have a concern is eye care. I'm not sure what they do in the schools. I'm not sure what we do in the Health Department. But a child that has a vision problem, and you've all seen the commercials on TV how it can really have such a negative impact on their life, the ability to see, especially when nobody detects the fact that they are having difficulty seeing the blackboard or being able to read. What are we doing in the area of eye care, whether it's an examination and a referral or providing eyeglasses? What do we do to help monitor the vision of our young people, and for the same sake, our older folks also? COMMISSIONER DOMZALSKI: Vision care is very important. Part of our program in the health centers, children do get evaluated and eyeglasses are part of that. But here's where the issue is in terms of insurance. There's program called EPSDT, Early Periodic Screening and Testing Service Program. And under that 131 04/21/04 - WHOLE - BILL 040255 program, there's a requirement that vision screening be done. And in fact, eyeglasses, corrective lenses can be supplied under that program. So that's part of our health center operation. All children essentially who are in our system -- and there's an exception, but that might only be or percent at max. So virtually all children are insurable in some way in the centers, and so we're able to access care for children. I know Paul Vallas has been very concerned about eye care in the schools as well, and he's been trying to bring in the Medicaid managed care company to assist with that as well.

Are you coordinated in any way? I mean, I have no clue what they do at the School District. I'm not sure whether there is screening for the students. I'm not sure what the screening process is. But let me just give you a scenario. A mom brings the child. You find that there's a condition, their vision is not good. Will eventually 132 04/21/04 - WHOLE - BILL 040255 that child be examined and, if needed, will that child have glasses? COMMISSIONER DOMZALSKI: If it's detected -- you're talking about the child's problem being detected in the school?

No -- COMMISSIONER DOMZALSKI: The child will be screened.

And will have glasses eventually. COMMISSIONER DOMZALSKI: Yes. Yes. The hesitancy is whether or not we've got the EPSDT Program up and operating in terms of the coverage for that child. So we'll do everything necessary to be able to hook that child up with glasses.

If I person didn't qualify for insurance, they would leave the center with a problem? I think you know where I'm going here. Would there ever been a situation where we would knowing let a child out of that center after a few weeks of knowledge that that person had a vision problem and they 133 04/21/04 - WHOLE - BILL 040255 wanted glasses and they wouldn't get them? COMMISSIONER DOMZALSKI: No, they should not be. We should be working with a variety either through the EPSDT Program or through the managed care company to be able to get lenses for that child.

What if one of our folder folks comes in or maybe not so old and they have a cataract or some issue like that, how do we deal with that? COMMISSIONER DOMZALSKI: I think we'd probably deal with that around whatever provisions involved in Medicare. I do know for our residents who are in our Riverview Home, we have a relationship with the Pennsylvania College of Optometry where they actually provide services onsite and provide lenses.

I think it might be -- and I know that you're on top of the game over there. But I think it wouldn't be a bad idea to sit down with the School District and maybe get together. We're talking about this reaching out to each other. I think 134 04/21/04 - WHOLE - BILL 040255 there might be a little bit of disconnect. I don't want to be specific in what the School District does and what you do. I think it might be worth having a conversation. Not you personally, one of your staff to see -- COMMISSIONER DOMZALSKI: I'll be happy to do that.

Because I did hear that it was very difficult for some of our young people to get some help vision issues. COMMISSIONER DOMZALSKI: Well, I think I'd like to talk to you about that in a little more detail. And I'll also be very happy to reach to the School District on that issue.

Thanks. Appreciate it. Thank you, Madam President.

Thank you. The Chair recognizes Councilwoman Tasco.

Thank you very much. 135 04/21/04 - WHOLE - BILL 040255 Commissioner, in looking through the budget book and the number of providers that you have, I notice there are two providers that receive a large amount of funding from the Health Department. I'd like to know who they are, what services they provide, who they provide those services to, and how do they provide those services. One is Philadelphia Mental Healthcare Corporation, and the other one is Philadelphia Health Management Corporation. COMMISSIONER DOMZALSKI: These are agencies that we contract with to help us provide services, to get the services done that we need that are a little bit outside of our regular systems in the Department. Picking up on Philadelphia Health Management, we probably have somewhere around contracts with Philadelphia Health 21 Management Corporation. And they provide a 22 range of services that go from providing technical support to some of our community-based organizations to actually providing the business office support for our 136 04/21/04 - WHOLE - BILL 040255 animal control program. So it's a wide rage of services that they provide. On the behavioral health side, there's also a number of services, direct services and service agencies that are funded through those mechanisms.

Now, is this a bid contract or is this just a professional service contract that you grant to them without a bid? COMMISSIONER DOMZALSKI: Usually it's not bid.

How about the Philadelphia Mental Healthcare Corporation, who are they and what do they provide? COMMISSIONER DOMZALSKI: This is a somewhat similar -- and I have to say somewhat similar in that Philadelphia Health Management Corporation provides a very broad range of services, including doing a community database and a household survey and the rest of it around the physical health aspects of service delivery in the City. The Philadelphia Mental Health, PMHCC kind of grew up around the 137 04/21/04 - WHOLE - BILL 040255 behavioral health system, and they provide not the same but a similar array of services that I think Mike Covone could talk about in better detail than I can when he comes up.

Well, under the Philadelphia Health Management Corporation, are there other agencies in the City who could do those same services? And why do you not put it out for bid? COMMISSIONER DOMZALSKI: These are professional services contracts so we're not bound by Charter to do it. If there's an agency where -- often times we just don't have other agencies that are competing in the same area of service as --

But you've not put a contract out for any service that they might be able to perform that you give them a no-bid contract for. You don't put that service out for bid for any other organization that may be able to provide that service. COMMISSIONER DOMZALSKI: Well, there are other organizations that we've begun to use. In the beginning, Philadelphia Health 138 04/21/04 - WHOLE - BILL 040255 Management Corporation just had the services that were needed and they had them most readily available. They're not that exclusive anymore. We also do business with other organizations such as the Health Federation for comparable services but not on the same scale sometimes as PHMC.

Who do these large organizations do business with? Who is their constituency? Do they have staff to perform these services that they provide to you, or do they subcontract out the services to other entities for the Health Department? You give them money for technical services for community organizations. Do they have in-house staff to perform the technical services or do they contract that out? And if they do, who are they contracting out to? COMMISSIONER DOMZALSKI: Sometimes it's both. With, for example, with the Health Federation, we employ a lot of our benefits counselors that are located in the health centers through the Health Federation. They 139 04/21/04 - WHOLE - BILL 040255 become Health Federation employees and they're detailed to do our work in the Health Department.

I'm talking about these two organizations that provide programatic service to the community. I don't remember all of the services that they provide, but some of the services they provide -- it's about $2 million worth of stuff I see, plus more. Do they have in-house staff to provide all the services that they contract Department of Health, or do they subcontract that? If they do, I'd like to know who the subcontractors are and I'd like to know the neighborhoods that they're doing the work in. COMMISSIONER DOMZALSKI: We can supply that.

And I'd also like to know some of the services they are providing, are there other groups in this City who can perform the same work. I mean, we're back to where we had the disparity issue around the minority MBE program in the City and the lack of minority 140 04/21/04 - WHOLE - BILL 040255 participation. When the majority of the clients in the City tend to be minority, then who are the minority contracts and service and program providers that are reaching out and serving them? Is it just large providers who have no connection to the community? These community-based programs that could do the work and they could get a no-bid contract too. You could give them a professional services contract. But when it comes to them, it seems that they've got to bid and they've got to compete. They've got to compete against each other. They have to fight for crumbs while millions of dollars are going to larger providers and they don't have to compete. They can just get a professional service contract. COMMISSIONER DOMZALSKI: Some of our contracts -- and I know these are not the ones you're talking about -- with large hospitals, we do contracting with them.

I'm not talking about hospitals. I'm talking about Philadelphia Health Management Corporation. 141 04/21/04 - WHOLE - BILL 040255 I'm talking about the Philadelphia Mental Health Corporation and some of the others in this book that are getting large numbers of health dollars. Hospitals we contract with because that's what we're supposed to do. We don't have a public health hospital so that's what we're supposed to do. I want to know who are they doing business with. I want to know diversity of their contracts and how they're given out. And I want to know why can't some of the contracts that they have can't be given out on a professional services basis to some of the community-based organizations that provide those same service. COMMISSIONER DOMZALSKI: We'll be happy to supply the information. Also, I'm going to say that in the Department we do have percent looking to go 21 to 25 percent. 22

Listen, I don't 23 24 or 25, I want as much as you can do. Don't 24 say, "Well, we're doing percent; that ought 25 to be good enough." 142 04/21/04 - WHOLE - BILL 040255 It's not good enough. We want it expanded to provide to those community groups who are struggling day-to-day to keep their organizations going, who get pennies from the Health Department while other providers get millions. The dollar value has to be -- there has to be some accountability for the parity of dollars that are spent with the groups who struggle with people every day in the community. COMMISSIONER DOMZALSKI: We agree.

I want to talk to you about the tobacco program you have. I see you have about $2.5 million for the tobacco program? COMMISSIONER DOMZALSKI: Yes.

Do you have a program in place for that yet? COMMISSIONER DOMZALSKI: Yes, we do.