COUNCIL OF THE CITY OF PHILADELPHIA PUBLIC HEARING COMMITTEE ON PUBLIC HEALTH AND HUMAN SERVICES and COMMITTEE ON PUBLIC SAFETY - - - Room 696, City Hall Philadelphia, Pennsylvania Tuesday, October 8, 2002 10:00 a.m. - - - RESOLUTION 010598 - Resolution authorizing City Council's Committees on Public Health and Human Services and Public Safety to hold a joint committee hearing to continue monitoring and investigating the quality level of medical and mental health care services that is provided or made accessible to prison inmates under the care of the Philadelphia Prison System, and further authorizing the Committee to issue subpoenas and such other process as may be appropriate to compel the attendance of witnesses and the production of documents in furtherance of the investigation to the full extent authorized by Section 2-401 of the Home Rule Charter. - - - PRESENT: COUNCILMAN ANGEL ORTIZ, Chair COUNCILWOMAN MARIAN B. TASCO, Chair COUNCILWOMAN BLONDEL REYNOLDS-BROWN COUNCILMAN DARRELL CLARKE COUNCILMAN W. WILSON GOODE, JR. COUNCILWOMAN DONNA REED MILLER COUNCILMAN FRANK RIZZO - - - VINCENT VARALLO ASSOCIATES, INC. Registered Professional Reporters Eleven Penn Center 1835 Market Street, Suite 600 Philadelphia, Pennsylvania 19103 (215) 561-2220 I N D E X RESOLUTION 010598 PAGE TIMOTHY GILL, Deputy Managing Director ...... RICHARD HELENDER (ph), Regional Medical Director for Prison Health Services ............. 34 CHERYL KRITZ, City Solicitor ................ 41 ELLEN STEIKER, Deputy Managing Director ..... 44 THOMAS COSTELLO, Commissioner of Prisons .... 58 NINA GORMAN, Coordinator, Prison Health Advocacy Project ....................... 64 3 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
A resolution authorizing City Council's Committee on Public Health and Human Services and Public Safety to hold a joint committee hearing to continue monitoring and investigating the quality level of medical and mental healthcare services that is provided or made accessible to prison inmates under the care of the Philadelphia Prison System, and further authorizing the committee to issue subpoenas and such other processes as may be appropriate to compel the attendance of witnesses and the production of documents and furtherance of the investigation to the full extent authorized by Section 2-401 of the Home Rule Charter.
Thank you. I'd like to recognize Councilman Frank Rizzo, Blondel Reynolds-Brown is here also. I want to welcome you and thank you for coming. And I want you to excuse me, but I'm under stress in terms on antibiotics. I seem to have some sort of bronchial condition. It has me really speaking with this very weird voice today. Since January 2000, this committee has 4 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 been investigating the nature and scope of healthcare in our prison system. In that time, this committee has worked diligently to assess the degree to which PHS, the private provider of prison healthcare, has performed. What we found was astounding. There was a range of baffling mishaps and instances of neglect that puzzled the minds of all of us concerned with ensuring we complied with the most fundamental obligations we as a City have to the inmate population. We found there were a long list of administrative and medical care deficiencies that in some instances led to the unjustified and often unexplained deaths of too many inmates. In April and May of this year, for example, there were two inmate suicides that were in part due to what City consultant Dr. Raymond Patterson described as an absence of policy or procedure which assure routine and timely comprehensive behavioral assessments. He suggested that some of these suicide cases were preventable if appropriate referrals had been generated. Dr. Patterson concludes in his most recent quarterly report that the inmate records he reviewed to date 5 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 clearly indicate a need for an integrated comprehensive treatment planning process. This, of course, is not new to the City. In fact, it is the cornerstone of Managing Director's Estelle Richman's January 2000 report to this Council. More so, this committee's report which was approved by City Council this past June clearly outlined the elements necessary to ensure improvements in the delivery of prison health services. The report included recommendations for the new contract cycle in light of PHS' June announcement that it would not continue its role as health provider. 9 million extension was negotiated with PHS. Meanwhile, a new request for proposal was written. That, in our opinion, was a significant improvement over a prior RFPs. The new RFP included a comprehensive set of measurable goals and objectives and even clarified several of Council's prior concern about the lack of penalties for non-performance. Our understanding is that there was a mandatory bid conference and competitive bidders submitted their proposals. 6 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 2 million. 1 million, a startling percent increase. 9 This Council needs to know the details 10 justifying this increase, especially the realization 11 of a contract with a firm who just three months ago 12 increased its standing among its stockholders by 13 alerting them that they would terminate what they 14 define as a loss contract with the City. I am aware 15 that according to the City consultants that monitor 16 this contract, improvements have been made by PHS. 17 We know much of this progress is a consequence of 18 this Council's watchdog role and critical work of 19 the City monitors, Dr. Griefinger and Dr. Patterson. 20 But many challenges still remain and need to be 21 addressed. 22 Over the last two years, we have learned 23 much about our prison health service delivery 24 system. We know that inmates obviously receive a 25 different standard of care, too often unjustifiably 7 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 substandard. The introduction of a private provider in the early '90s was a clear response to the long-term neglect evident when these services were under City management. But much has changed over the course of the last few decades. , Edison in the school system. On the other hand, the public sector has improved its capacity to deliver human services.
Our inquiry is not about placing blame on private providers like PHS, it is about what standard of care we as a City genuinely believe should be provided to the inmate population, many of whom are pretrial detainees. The preliminary results of our inquiry has convinced me that we as a City need to have a greater management control of the delivery of healthcare services. A private provider is obviously an interim measure. Therefore, it is time we explore alternative models to prison healthcare that make sense for a City like Philadelphia. We also found that most private 8 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 providers are highly reluctant to be held accountable. Monitoring the progress of PHS has been dependent on the internal reports of the City consultants. But even they have expressed frustration over the City's and the provider's slow and inconsistent response to their recommendations. Obviously, City Council's observation that an independent oversight committee be established is well-deserved and long overdue. Today, we are here to obtain some answers to the questions outlined in the aforementioned, as well as those questions we have submitted in writing to the City Administration. I don't expect an avalanche of responses, but our job is to continue the mandate set before us by this legislature as specified in Resolution 010598. I want to, again, thank all the community activists for their support and guidance. I hope to count on their continued advocacy and expertise. From the Philadelphia County Prison Coalition, I want to thank in particular Asia Russel and Robert O'Brien who have been collaborating with this committee from the very beginning. I also want to recognize the work of 9 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 Temple Professor Nina Gorman who has conducted a preliminary literature review in her efforts to help us explore the structure and work of a prison health oversight committee. We will hear a summary of her report today. I also want to extend my appreciation to those Administration officials here today who have consistently responded to our request for information. In particular, I want to thank City Solicitor's Office despite our constant struggle and from the Managing Director's Office Mr. Timothy Gill who has tried to be responsive to our requests for information. While we may not always agree on how and when things should get done, I acknowledge his cooperative spirit and support of our work. In the end, I am confident we all want the same thing: To ensure we fulfill a legal and moral obligation in providing quality prison healthcare. Thank you all for being here. Councilwoman Tasco, the Chair of the Health Committee has just arrived. Please call the first witness. Timothy.
Good morning, Mr. Chairman and members of the Public Safety Committee. I am 10 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 Timothy Gill, Deputy Managing Director, and it is my pleasure to represent Managing Director Estelle Richman for the purpose of presenting our progress on the Philadelphia Prison System's healthcare and related operations issues. With the benefit of your committee's request for information as an outline, we have prepared a sketch of the issues to present and have on hand a team of representatives to address your follow-up questions. With us today are members of the Managing Director's Office, Philadelphia prison system, Law Department, Office of Mental Health, and our medical services provider. Although Prison Health Services was not a bidder in the RFP process, the RFP upon which the City's contract with PHS is based expressly reserves to the City the right to negotiate with providers who did not respond to the RFP. Specifically, Section 6.1 the City's reservation of rights states as follows: "In the event negotiations with any respondents are not satisfactory to the City, the City reserves the right to discontinue such negotiations at any time; to enter into or continue negotiations with other respondents; to enter into 11 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 negotiations with providers that did not respond to this RFP; and/or to solicit new proposals from providers that did not respond to this RFP. The City reserves the right to enter into any contract with any respondent, with or without the re-issuance of this RFP, if the City determines that such is in the City's best interest." The terms and conditions of the contract amendment have been forwarded to your office. The scope of services is based primarily on the 2000 contract with minor adjustments described in Exhibit PA-1. The duration of this contract amendment is nine months from 10/1/02 to 6/30/03. The City will monitor the contract. The monitoring process involves the established blend of external independent monitoring experts and internal daily operation evaluators. The specific components of this team remain independent medical and behavioral healthcare experts, correctional healthcare specialists, correctional nursing monitors, and objective oversight by an agency not connected to the prison system. The standards of care referenced match those established by the National Commission on Correctional Healthcare. Our 12 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 approach is adaptive in nature by working with the provider early on and continuously to address problems with healthcare in a cooperative manner, rather than adversarial. We think the partnership approach has paid off in tackling difficult issues and has promoted flexibility in services that our patients benefit from. In Contract Amendment 0120146-04, the City reserves the right to conduct utilization review based on a community standard of care to help ensure that services will be provided in a cost effective manner. PHS will not be required to fulfill the contractual requirements outlined in the RFP issued July 9, 2002. The current agreement is an amendment to PHS's 2000 scope of services with the modifications explained earlier. In recent years, the medical services provider demonstrated dramatic losses suffered due to a variety of reasons driving escalating healthcare costs. In order to continue delivering medical services for our inmate population without losing money, City and PHS representatives negotiated terms of price and risk sharing that made it possible for them to provide services with 13 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 reduced threat of financial loss. The following is a budgetary and financial explanation of the contract and whether City Council approval will be required.
Excuse me. Could you explain that to me, that last sentence that you said because I have a series of questions, but --
No, the one, "In order to continue medical services for our inmate population without losing money, City and PHS representatives negotiated terms of price and risk sharing that made it possible for them to provide services with reduced threat of financial loss." Explain that to me, please.
The previous scenarios under which the contract was constructed with a full risk contract that capped the ability for compensation for either the services that were being provided, pharmacy, outpatient services, hospitalization or other services required by patients, then it was no 24 matter what the cost external to the services PHS was providing, there was no mechanism for them to be 14 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 able to receive additional compensation. What we tried to do was acknowledge what's happening in the healthcare industry around the country, and that is escalating costs that cannot be predicted or cannot be anticipated in affixed rate contract, the City would share and acknowledge if it's verifiable that those costs are escalating, would share in part of that expense.
For the period July 2000 through June 2002, PHS was reimbursed for actual costs of services up to a fixed price with an adjustment for increases in population above 6900 inmates and for costs per inmate in excess of $50,000 up to $200,000. million; for Fiscal Year 2002, the amount was $28 million. million. 6 million for '02. Based on the contract for Fiscal Year 03, which consists of Amendments 0120146-3 and 15 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 2 million. 7 million. 79 per inmate per day for a population in excess of 69 hundred inmates as well as compensation for costs in excess of $50,000 per inmate. Total costs for the period, including additional compensation, are projected at just under $9 million. 2 million. 2 million. In Amendment 4, additional compensation has been redefined. It no longer covers population in excess of 6900 inmates or costs per inmate in excess of $50,000. Rather, it covers costs in excess of what is included in base compensation, as 16 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 shown in Exhibit PA-4A for the following items: Malpractice insurance, hospital, specialty and ancillary services, pharmacy, lab testing for Hepatitis C, and hourly rates for eight employment categories as shown on Exhibit PA-4B. Given the variability of the costs that are eligible for additional compensation, we believe that it is in the interest of both the City and PHS to share the risk on these line items. In summary, the City budgeted about $30 million for Fiscal Year '03 for Prison Health Services. Based on the current contract, it could cost about $6 million more. It is too early to say whether the PPS will be able to live within its Class 200 appropriation or whether the Administration will need to come back to City Council for a transfer ordinance in Fiscal Year '03. In addition, as we do every year, the Administration will include costs for correctional health services in its next five-year plan and Fiscal Year '04 Operating Budget. The summer of 2002 was marked by record-setting heat waves. Although there were three unfortunate losses of inmate lives in July 17 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 2002, in one of them the excessive heat played a role. The other causes of deaths were cardiac death and end-stage alcohol liver disease. The facility in which excessive heat played a role in an inmate's death is not air-conditioned but utilizes all methods possible to maximize air ventilation and drinking water availability. Commissioner Costello has prepared a detailed response to the same issues, but in essence, increasing air ventilation in the housing areas is handled with a combination of open windows, fans, unit door opening management, and modified inmate uniforms to allow cooler clothing. Water is available in all cells with supplemental water coolers as needed. To support prevention officials from the Philadelphia Prison System, Managing Director's Office, Health Department, and others were quickly and collaboratively to develop a directive implemented by PPS titled "Heat Alert Plans," which forms the basis of actions to take when excessive heat in the jail reaches emergency levels. A copy of the Heat Alert Plans has been forwarded to your office for review. 18 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 The Administration is aware of City Council's committee report on Resolution No. 010598 to establish an independent oversight board. However, we feel the current array of independent experts in the fields of medicine, medical administration and behavioral health ensures appropriate levels of accountability, monitors complaints, and measures the performance of the prison health provider. Indeed, the monitors have noted improvements in many key areas with further work needed in others. The City will continue to monitor the healthcare services and work towards continuous improvement with the approach described earlier.
Our prison health service provider continues to exceed the minimum participation levels established by the City's Minority Business Enterprise Council. A current MBEC participation chart has been forwarded to your office. Recently, there was an impromptu meeting held at the prison for employees represented by Union Local 1199C, which is the bargaining unit for nurses and related healthcare workers. The employees were frustrated by the lack of information 19 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 available regarding their future employment since the cessation of the contract for their employer was fast approaching. When a contract agreement was reached, the employees' concerns were answered. 1199C negotiates wages on behalf of its members and agrees to the terms and limits. These wages are comparable prevailing wages in area healthcare settings. The City has certain procedures to identify, track, counsel, and treat inmates with Hepatitis C currently in place. We have designed a medical intake system that requires the healthcare provider to repeatedly question the patient at different stages of the intake process as to the possibility of hepatitis exposure or the use of drugs related to hepatitis. In addition, all patients are given ample opportunity to request confidential counseling in testing either with the prison healthcare provider or through AACO. Often, the first contact that a patient has with the prison healthcare provider is at the Police Administration Building where a medical screen is performed using pointed questions aimed at determining the patient's health status. Hepatitis 20 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 is one the items specifically asked of each and every patient seen at the PAB. At the intake facilities of the Philadelphia Prison System, the patient is placed in a holding cell in which there are bilingual signs reminding the patient to inform the prison healthcare provider of any medical problems they may have. The receiving room nurses make regular rounds throughout the holding area to give patients ample time to notify staff if they are in acute need. The intake medical screen performed by an experienced RN also has pointed questions aimed at specific diseases. If at any time the patient states that he or she has hepatitis or asks to be tested, the inmate will be referred to chronic care for evaluation. Any patient showing signs of acute illness or being suspect of needing urgent care is immediately referred to the physician on duty for evaluation. Any patient identified as having HIV disease is routinely referred to chronic care and as part of the evaluation is screened for exposure to hepatitis. After the medical intake screen, the patient will have an admitting history and physical performed by either a physician assistant or a 21 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 physician. As part of the routine history, there are several questions leading towards documenting hepatitis exposure. There are direct questions specifically about hepatitis as well. Any patient documented as having Hepatitis C is referred to the chronic care system for evaluation and consideration for treatment. All Hep C patients are screened for exposure to Hep A and B. HIV testing is strongly recommended. Liver enzymes and pigments are routinely examined. The patient is always counseled as to prevention and life-style modification. The patient will be followed for alterations in the liver functions profile. Further discussion to consider medication includes genotyping, side effects, liver biopsy, and behavioral health examinations. Proper histology as documented by biopsy is essential to classify the patient in a medication protocol. As the medications are known to cause behavioral health problems, baseline behavioral health evaluations are necessary to diminish the potential for psychiatric morbidity. The diagnosis and preparation for 22 10/08/02 - HEALTH, PUBLIC SAFETY - RES.
010598 medications may take months, which for some patients may mean they are discharged from PPS before receiving medications and treatments. This is not uncommon considering average length of stay for inmates at PPS is approximately 77 days. Many of these patients will only be partly evaluated for medication protocols. Comparison of our county system to that of the federal or state system is inappropriate, as our length of stay is much shorter limiting our ability to coordinate the long-term diagnosis and treatment required for Hep C. State correctional facilities have patients for years which allow comprehensive planning and guaranteed treatment follow-through. As the documentation of the health risks of Hep C in prison settings is still emerging, the City hopes to develop policy to most effectively deal with the issue that includes PPS, the Department of Health, AACO, and community providers to ensure long-term treatments. The Managing Director continues to explore alternative funding and programmatic models for correctional health services. While no 25 successful alternative model has been found at this 23 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 point, we continue to explore options. There have been some discussions regarding a nonprofit model that could be patterned after similar agencies in other jurisdictions and health-related fields. As this is quite preliminary, it would not be appropriate to venture into details not thoroughly analyzed for public debate. We will keep you informed of developments in this area. Finally, the June Drs. Griefinger and Patterson reports have been sent to your attention. There are no September reports, as the monitors have not performed inspections. They are scheduled for the end of this month. This concludes my testimony at this time. Our team of representatives will remain for as long as necessary to address the Public Safety Committee's follow-up questions. Thank you.
Thank you, Tim. One question to begin with. The City put out an RFP, and in that RFP they made certain requirements that each individual that submitted a bid had to abide by. However, the contract that you have given PHS is not based on the RFP that was put out, but is just an amendment to the old contract and it doesn't 24 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 reflect any of the requirements of the RFP in there. Why was that?
Well, although I stated that the City exercised its right to be able to do that, I'd like to give you a little bit of information as to what was the reasoning for us to exercise that right. And primarily, because of submissions that we had received for the 2002 RFP, we had only received two bona fide submissions. The pricing that was part of those proposals, the limitations and the restrictions that the respondents had insisted needed to be a part of their involvement with Philadelphia's Prison System made them not as attractive as the potential for using the incumbent provider with the set of scope of services which we had already been prepared to utilize until the year 2004. The ability for the incumbent to have a better handle on what the related costs or associated challenges are of providing services in Philadelphia coupled with the improvements noted by Drs. Griefinger and Patterson in their services and their performance and their ability to more closely meet the financial needs of the City of Philadelphia made it a good decision to entertain having PHS be 25 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 able to enter in the negotiations with the City and see if we couldn't come to an agreement or a pricing structure or a risk-sharing structure that would benefit both the City and the patients in the prison system.
But you put out an RFP, and I have it here and it's kind of big and heavy. And in my weakened condition it's really testing my arm here.
And then you in essence obviate all of the new conditions of this RFP, which I think were quite an improvement over the other RFP of prior years. And then you give PHS an added contract for two months and then just amend the old contract without having any of the conditions of the RFP included. And I don't understand that. Can you give me -- what were the other companies that submitted bids? Do you have their names?
And what else, Wexler? 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
Well, we had begun analysis with a team of evaluators from around the City agencies. I don't have all the specific points of rejection from each of them. But in essence, essentially in part pricing structure and also --
When you say pricing structure, give me an example. They wanted more than $36 million that we're giving PHS?
In my years of experience in bidding out contract work, I never know why contractors assign the pricing that they do or their basis for which -- 27 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
No. Actually, both respondents submitted quite a bit of exceptions to the RFP, which bidders are welcome to do. Although the City sets standards and the City applies what it thinks is appropriate for conducting business, the structure of pricing, the services to be provided and such, contractors are allowed to submit what they believe are their exceptions to what we want. And both of them had considerable amount of exceptions.
What was the base that was put forward by the City to these other companies? Was it $36 million or less or what? And how high did they come in?
We did not project a target figure, if that's what you mean by a base. We did not project a target figure for them to come in at.
The terms and conditions of each of the respondents were -- they're a mixture of the exceptions. I'm not trying to be vague. It's 28 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 just that the mixture of their exceptions and what they wanted to share in costing aggregates doesn't allow for an even number to compare to, but both were significantly higher than 36 million.
Were there any requests for a re-bid to these companies telling them that they were too high and to re-formulate their bids?
And did we make the request of PHS to meet the requirements of the RFP? Obviously we did. The other bidders were bidding according to the RFP. Obviously, PHS did not make a bid, right?
So you just extended to them a contract without them going through the RFP and the requirements of the RFP as put forward by the City?
Just to be accurate, it was an amendment, not an extension. It was an amendment to the existing 2000 agreement which the City had already had in place -- 29 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
But, again, you did not require them to, in essence, meet the requirements of the RFP?
Not the 2002. They are meeting the requirements of the 2000 RFP.
What were the exceptions and the liabilities that you're talking about?
I'm not prepared. I don't have them with me. But we can surely get them to your office.
You say that PHS is going to, in your testimony, meet the standards of the NCCHC. Is there a time line for them to meet those standards?
Well, I guess the short answer is I wish it was yesterday. But we are working with them on an ongoing basis that those are 30 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 met. We've received renewed commitments from their corporate structure that they will work with us and get them as quickly as possible, but I do not have a date that I can tell you is the exact deadline for which they will be meeting all of them. It's the guidelines that --
They have nine months. What's the time line you're giving them?
Like I was about to say, the guidelines are what we're using as a basis for which they will be referring to that they will meet those requirements. And, again, I don't have an exact deadline for that.
And if they don't meet the deadline, are there any penalties for that?
Well, if you mean structured penalties for financial penalties, the City does reserve the right to do that if it feels as though that the contractor is unresponsive and not working.
I don't have the section, but I think I've referred to that in previous responses to your office, Mr. Chairman, that there is a 31 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 section in the RFP that the City reserves that right to impose liquidated damages if it deems necessary that the contractor is not responding.
In the lifespan of PHS history with the City, has there ever been any penalties that the City has --
Will PHS be required to provide hours per day, 7 days a week medical 13 services? 14
And for Hepatitis C, 16 will PHS be required to provide a comprehensive set 17 of protocols designed to manage chronic diseases, 18 including within 30 days of contract? Have they 19 provided a set of protocols to deal with Hepatitis C 20 and other chronic diseases? 21
They have not submitted a set 22 of protocols, but if I understand what you mean by 23 protocols correctly, the basis for which they'll 24 systematically address the Hepatitis C issues, it is our intention to bring the Health Department, AACO, 32 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 community providers and consult with Dr. Griefinger on what his experiences have been in his work, I believe, the CDC in helping us develop exactly what model works best for us in our county jail system. There are other protocols that we're aware of that exist at the state level or perhaps the federal level where their environment allows for longer term of care because their patients are with them longer. We need to develop a much more complicated network that involves outside providers outside of the jail walls so that we can make sure that the continued care happens even when they're out of my jurisdiction. So that protocol is not firmly in place, but that is our intention to work quickly to have that in place. It's a very topical item right now. It's an emerging medical condition and issue that we want to try and get ahead of the curve on.
I believe we're meeting with Dr. Griefinger in about two weeks to begin that process.
We've got testimony here from inmates that they have requested sick 33 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 calls, and activists, and they were not seen within hours of that request. Is that going to change? 4 If an inmate makes a sick call request, will he be 5 seen within 24 hours of the request? 6
I'm aware that there are 7 isolated incidents when with the shear volume of 8 sick call requests that are put in place in various 9 institutions that there are times when a patient may 10 not be seen within that 24 hours, but they are -- 11 the sick call requests are reviewed by a health 12 professional no less than an RN, and they are 13 categorized and utilized as a way of getting to the 14 most urgent and emergent patients possible. I know 15 that there has been some review of the sick call 16 requests by PPS operations and that they found that 17 in general that the responses have been pretty good. 18 But if there are specific patients that have chronic 19 issues of not being able to get the sick call, our 20 office would like to know that so that we can make 21 sure that it's the facility that we address as their 22 medical team is not getting to the patients quickly 23 enough. But I think in general, the results have 24 been pretty good in getting to sick call.
What will PHS do to 34 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 ensure segregation medical lock-in inmates are visited by a healthcare professional every day to determine need for medical attention?
Well, we have some representatives who oversee that portion of the operation in medical, and I think that they could probably give you a better insight as to what their process is now.
And if you're identified with a chronic illness such as Hepatitis C --
Excuse me. I want to say that Councilman Darrell Clarke is here and Councilman Wilson Goode. Go ahead.
I'm Dr. Richard Helender. I'm the Regional Medical Director for Prison Health Services at the Philadelphia Prison System. 35 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
The question is how are we going to ensure that patients that are kept in isolation are seen every day.
We have a process now, one of the RNs in each jail has a log that she keeps. She visits each and every patient in that log every day and documents the visit. That's done seven days a week. And the log is available for review.
All right. And the inmates identified with chronic illnesses, Mr. Gill, are they seen? What's the time line for their appointments, two days, three days, two weeks?
That's something I'd like the medical director to respond to as well.
Inmates are put into our chronic care system as urgently as is necessary. The current RFP allows us 30 days to see them in their first visit. That will allow us to get the more ill of the patients in quicker.
30 days? 36 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
So you're suffering from Hepatitis C and you have been identified, you have to wait 30 days?
Excuse me. I may have misspoke. I'm right 30 days. I didn't mean to interrupt you. I'm sorry.
An inmate that is identified with chronic illnesses, he is going to be seen in the chronic care clinic within 30 days?
It may be 72 hours, it may be the next day depending upon the urgency of the need. The physician who is seeing that patient, making the referral or the physician's assistant he determines the urgency for the visit. That patient may be seen the same day by a physician in chronic care. We don't necessarily wait 30 days. We get them in as quickly as is needed.
So if an inmate is referred to you and then you make a determination, you tell him to come back according to your 37 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 determination, two weeks, 30 days?
Is the HIV clinic going to operate three days per week or more? And will an inmate not have to wait more than seven days for an appointment with the infectious disease clinic physician?
We have an infectious disease clinic, yes. She's on campus five days a week -- I'm sorry, four days a week.
How long does somebody have to wait for an appointment?
I don't -- again, we get them to see her as quickly as necessary. It may be two weeks, it may be a little bit longer, it may be a lot shorter.
Thank you, Mr. Chairman. 38 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 Follow-up question. You said she's on campus five days a week?
The urgency of the need. There are patients that come in -- we're specifically talking about HIV here. There are 39 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 patients that come in that need to be seen the next day or the next two days. If she's on campus in the intake housing that day, they may be seen that day. If they're stable, it may take two weeks. It may take a little bit longer.
We've had testimony here from inmates that that was not the case in terms of HIV and others, that they had to wait to be seen by a doctor for more than a week. And you're telling me that that is going to be changing?
No, I'm not going to tell you that's going to be changed. There are cases where a patient will wait longer than a week to be seen by a physician. That's not going to change. The patients are seen as needed. If they need to be seen emergently, they're seen by the physician on duty that day. There will be patients that wait longer than a week to see the physician. If they need to be seen sooner, they'll be seen sooner.
What staffing is present every day? What's your staffing? How many doctors are there, how many nurses are there? 40 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
What's your staffing daily in terms of -- and how many patients do you see a day in each of these clinics?
In each of the jails there is a physician Monday through Friday 8 to 4.
No. In several of the jails there are physicians available 4:00 to 12:00 and in two of the jails there are physicians around the clock. This is both the chief medical officer as well as clinic physician. Several of the jails have two physicians from 8:00 to 4:00. This does not take into account our independent consultants. These are our staff physicians. There's always a physician on campus, at least one.
Many registered nurses. I can't give you that number. 41 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
Mr. Gill, obviously, there are no differences between this new contract and the old contract, right?
Well, there are some changes, as I referred to in testimony, that are described in the exhibits that were part of the documents that I had sent to your office earlier.
Good morning. My name is 42 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 Cheryl Kritz. I'm with the City Solicitor's Office.
There were modifications made to the insurance requirements that are reflected on Exhibit PA3 of the amendment.
The primary modification was in the area of professional liability insurance which was a decision made in conjunction with the City's Office of Risk Management. Unfortunately, they're not here today. But they were in response to the market conditions in the insurance industry as of late and they are reflected principally in Section D3 on Exhibit PA3 of the amendment. There were also modifications made to the general liability insurance limits as well.
What is the cost of that? I mean, what does that reflect, those changes?
Under general liability, the 43 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 limits for the period October 1st to December 31st of '02 remain the same as in the prior contract. And as of January 1, '03, the limits were modified to $1 million per occurrence and 5 million general aggregate. And that was the result of negotiation between the City's Office of Risk Management and PHS.
You never entered into any negotiations with the other bidders, right, in which these limitations and so on were discussed?
I recall that there were discussions between the City's Office of Risk Management and the risk managers of at least one of the other bidders.
Is there a way that you can provide us with a comparison of the rejected bidders with PHS?
Yes. I mean, you gave PHS basically the same contract, you didn't follow the RFP. I'd just like to see what --
Sure. I'm sure we can work something up for you. 44 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
I'd like to see that. We increased -- the contract of PHS is an increase of around percent over the overall 5 contract of 2002, right? Or 2001 to 2002? I mean, 6 it goes from 28 to 36 million or 38 million. Which 7 is it? I saw two figures, Timothy, 36 million 8 point something or 38 million something. 9
This is Ellen Steiker, 10 Deputy Managing Director from the Director's Office. 11 Good morning. 12
The contract for FY '02 14 had reimbursements, as was mentioned in the 15 testimony, of 28 million. And this resulted in a 16 loss for PHS of $4.6 million because the costs that 17 -- their actual costs as submitted on invoices to us 18 were $32.6 million. So really, when you look at an 19 increase year-to-year you need to be looking at 20 what -- 21
When you're looking at a 23 year-to-year comparison, what you need to be looking 24 at is what it costs in FY '02 to run the contract as 25 opposed to what we paid. 45 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
You know what was surprising, you said that PHS had a $4 million loss so we're compensating for that loss. You know, I would imagine that if you contract for service, you have to provide that service. And were all the monitoring reports that we got -- each of the reports actually made it clear that throughout the life of PHS's contract with the City of Philadelphia from '96 to now, they never had a full staffing of medical services. I mean, that was the one constant in all of the monitoring reports, that the staffing levels -- that PHS never achieved full staffing levels of their program. And they get a contract and it's percent increase. It goes from $28 16 million to around 36 to $38 million. I don't know 17 which one it is. Is it 38 or 36? 18
And for that, is that 21 just a reflection of the market in terms of the 22 increase of health services or PHS committing itself 23 to have full staffing through the life of this 24 contract and provide new services? What are the 25 differences? Or is this just a reflection of the 46 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 market?
Both the previous contract and the current contract reimburses Prison Health Services for actual costs. The difference between the previous contract and the current one is in the previous contract reimbursement was capped at a fixed amount which last year was approximately $28 million. There was some areas where there was additional compensation, and that was based on the population and on certain catastrophic costs above 50,000 up to 200,000. So those were the only instances where you could pay actual costs above the fixed amount. Under the current contract --
It is based on 6900 population of inmates, right, the contract?
This contract does not base additional compensation on population. We changed the structure under which we provide additional compensation. And the basis of 47 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 additional compensation was listed in the testimony and also in the contract amendment, but I can summarize what some of the differences are, if you'd like.
Under the current contract, we pay base compensation -- actual costs up to base compensation of $26.2 million. In addition, if certain categories of costs exceed the amount that's in the budget --
The categories are those categories that had the most variability and uncertainty to them. And because they were uncertain and variable, it was difficult to come to an agreement on what would be a fair amount under a fixed price contract. So we felt that we would rather just look at the actual cost of those services, and if there were some amounts that exceeded the base compensation that we would reimburse PHS for those amounts. And those were malpractice insurance, hospital specialty and ancillary costs subject to PHS submission of actual 48 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 claims documentation acceptable to the City. Pharmacy costs, cost of lab testing for Hepatitis C, and hourly rates for the following positions: Registered nurse, licensed practical nurse, physician assistant, nurse practitioner, psychiatrist, master's level social worker, psychiatric aid, medical records' clerk, and medical assistant.
Those are not definable costs? A psychiatrist and -- that's not definable. Don't you usually employ a psychiatrist for a certain salary, or what?
We actually believe -- the City, when we went into this negotiation believed that the budget for base compensation is reasonable and we do believe, in fact, that it will probably be adequate to cover these costs. However, there was an uncertainty related to providing service when there were absences for vacation or because of vacancies. And often, when you get a replacement in a very quick turnaround, you may end up paying a premium for those costs.
So the City picks up the premium, not PHS? 49 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 The thing is, that I thought the variable would be and the increase in cost would be in terms of the healthcare market, in terms of drugs increase in price, medicine, all types of medicine increase in price, and I thought that sort of a variable, given the way the market is today. But what you're describing to me, I think PHS says we're a company. We have these people. We have these doctors, these nurses, and we're going to deliver services to you for $36 million. And we have psychiatrists available. We have nurses available. We will hire those nurses within the spectrum and the scope of $36 million. And those will be available 365 days during the year and 7 days a week. But I didn't know that they're going to come to the City and say, "You know, we really don't have a psychiatrist. We're going to need to go out and hire one and we're going to add that cost to the contract." I thought that was part -- shouldn't that be part of the contract? Shouldn't that be part of what they have to provide?
We agree that pharmacy and hospital specialty ancillary as well malpractice are 50 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598 the largest --
I understand that. I just wanted to say that we agree that pharmacy, hospital specialty, ancillary and malpractice represent the largest variable costs, and we have a process at the end of the year to reconcile all of these costs and come to a fair resolution of any additional compensation.
And they're insured for malpractice, right? PHS is insured for malpractice?
And the City is insured, right? Are we carrying the cost of their malpractice insurance?
For the Philadelphia operation, that's correct. 51 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598
Shouldn't that be a risk that they take? Why should the City be liable for that?
I mean, they come in to provide a service and supposed to provide it in the most professional manner. Why should the City take the risk of their malfeasance?
The City is taking the risk on the costs of it because at the time that we put together the amendment, those costs weren't known for the period starting January 1. So we could not come to an agreement on what a fair cost would be.
So they can mess up and without any concern as to what because we're going to pick up that.
I wanted to add, Councilman, that under the contract PHS also agrees to indemnify us for their own acts or omissions, so we are sharing in the cost.
It's not limited by their insurance. 52 10/08/02 - HEALTH, PUBLIC SAFETY - RES. 010598