COUNCIL OF THE CITY OF PHILADELPHIA PUBLIC HEARING BEFORE THE COUNCIL COMMITTEE ON PUBLIC HEALTH AND HUMAN SERVICES - - - Room 696, City Hall Philadelphia, Pennsylvania Tuesday, 4/30/02 10:25 a.m. - - - BILL NO. 020165 - An ordinance authorizing the Managing Director, or her designee, to enter into an agreement on behalf of the City of Philadelphia with the Commonwealth of Pennsylvania, acting through its Department of Public Welfare, for the City to administer a managed care program under the name HealthChoices Behavioral Health under which behavioral mental health services will be provided to Philadelphia residents who are eligible for medical assistance, all under certain terms and conditions. PRESENT: Councilwoman Tasco, Chair Councilman Frank DiCicco Councilwoman Blondell Reynolds Brown Councilman Richard T. Mariano Councilwoman Donna Reed Miller Councilman Michael A. Nutter Councilman Angel L. Ortiz Councilman Frank Rizzo - - - VINCENT VARALLO ASSOCIATES, INC. Registered Professional Reporters Eleven Penn Center, Suite 600 Philadelphia, PA 19103 (215) 561-2220 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 INDEX WITNESS Estelle Richman, Managing Director............. Dr. Judith Dogin, Chief Medical Officer....... 19 Community Behavioral Health Philadelphia Behavioral Health System Ellen Steiker, Director, Financial Policy..... 34 Managing Director's Office Nancy Lucas, CEO, Community Behavioral Health 45 Mike Cavone, Deputy Commissioner.............. 56 Mental Health and Mental Retardation Cheryl Kritz, Esq., City Solicitor's Office... 79 Mark Bencivengo, CODAAP....................... 92 Anthony Arce, M.D. ........................... 99 North Philadelphia Health Systems Jeffrey Wilush, CEO, Horizon House............ 104 3 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
Good morning. I'm Councilwoman Marian Tasco, Chair of the City Council's Committee on Public Health and Human Services. This hearing will please come to order. We have a quorum in the presence of: Councilwoman Blondell Reynolds Brown, Councilman Ortiz, Councilman Mariano and myself and Councilwoman Donna Miller. The clerk will please read the title of the bill.
Bill No. 020165, an ordinance authorizing the Managing Director, or her designee, to enter into an agreement on behalf of the City of Philadelphia with the Commonwealth of Pennsylvania, acting through its Department of Public Welfare, for the City to administer a managed care program under the name HealthChoices Behavioral Health under which behavioral mental health services will be provided to Philadelphia residents who are eligible for medical assistance, all under certain terms and conditions. Thank you.
Thank you very 4 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 much. It is my pleasure this morning to welcome the administration, providers and consumers to offer testimony of this bill, which will reauthorize the agreement between the City, County of Philadelphia with the Commonwealth of Pennsylvania that will permit community behavioral to deliver behavioral mental health services to medical-assistance clients. This legislation will authorize the agreement between the City, the State, and CBH for a period of up to five years, one year, and four one-year renewals. I would also like to take some of this time as we talk this morning to gather information on the success of the program, the range of services provided, and their effectiveness, the provider organizations and their contractual duties, and the cost and diversity within the operation. We're also curious to know how we evaluate what we have accomplished since the program started and what our relationship is with the State. We will begin this morning with our 5 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 Managing Director, and she will identify herself for the record and proceed with her testimony.
Good morning, Councilpersons. I am Estelle Richman, Managing Director. Thank you for the opportunity to present today. Managing Medicaid dollars became a priority for states in the late 1980s and early 1990s. By 1994, the Pennsylvania Department of Public Welfare announced a pilot plan with for-profit maintenance organizations to manage both physical and behavioral health care for persons receiving Medicaid in Southeastern Pennsylvania. This approach received severe criticism due to the siphoning of dollars into layers of administrative expenditures and because the system created cumbersome hurdles for the most disabled persons who are least prepared to cope with them. State officials clearly recognized the need to improve the quality and accessibility for behavioral health care as a result of these initial pilots. In order to accomplish this, in February 1997, as part of the newly established HealthChoices program, the State decided to 6 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 separate, or carve out, the job of managing behavioral health-care services from the HMOs. This new plan ensures that incentives are in place to fully serve the mental health and substance abuse needs of the Medicaid population. In order to implement the carve-out, the State gave each county the right of first opportunity to either contract with a private managed-care organization specializing in mental health or to establish one of its own. This decision reflected the reality that counties have a 30-year history of providing behavioral health services and are uniquely positioned to design and coordinate a full array of programs. Philadelphia County decided to form its own managed-care organization. This decision was based on the extensive planning that Philadelphia County, in coordination with consumer and family groups and provider organizations, had been involved in since the 1980s. The resulting Behavioral Health System is a unified system that incorporates multiple funding streams in order to maximize dollars, accountability, accessibility, and quality. 7 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 Since February 1, 1997, the City, through its Department of Public Health, has managed the HealthChoices Behavioral Health Program under contract with the Commonwealth of Pennsylvania and Department of Public welfare. Under the contract, the City agrees to assume full risk under a capitated rate structure to pay for all medically necessary services for approximately 365,000 medical assistance-eligible persons. Although the City contracts with Community Behavioral Health, a nonprofit corporation created by the City to carry out the program on behalf of the City, CBH assumes none of the risks of management of the program; instead, it is the City that is contractually required to retain the risk for the program throughout the terms of the contract. To date, the City has protected that risk through a variety of required and elected financial reserve and reinsurance structures acceptable to the City and the Commonwealth. In order to achieve the goal of unifying funding streams, organizational oversight, and service-delivery systems, the major components of 8 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 the pre-existing fragmented delivery systems have been largely integrated into one system. The major components of the Behavioral Health System are the Philadelphia Office of Mental Health, the Coordination Office for Drug and Alcohol Abuse Programs, and Community Behavioral Health. The in-plan benefits available to all Medicaid recipients in Philadelphia County are integrated with the program-funded services available through OMH and CODAAP. Consequently, all behavioral health resources from outreach and intake through acute services such as inpatient psychiatric and detoxification, residential and vocational rehabilitation now receive funding from the integrated Behavioral Health System.
This integrated funding and regulatory environment dramatically increases and unifies provider incentives to support an integrative and consumer-centered service environment. Quality of care, accessibility, comprehensive service delivery, and consumer outcomes have been markedly enhanced. The HealthChoices Behavioral Health System has achieved a number of meaningful 9 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 service-related and fiscal accomplishments to date and include the following: cost savings resulting from the coordination of funding streams; the implementation of performance-driven payment system for contract provider and the reinvestment of $21 million in managed-care revenue into community services; development of new behavioral health-care services for older adults, including those who are home-bound and those who use City health services (more than 230 persons have benefitted from these new services to date); expansion and enhancement of outreach and treatment services for the Asian community (more than 4800 persons have benefitted from these services to date); development of additional acute care and support resources for families coping with children in crisis; comprehensive case management for children and adolescents with substance-abuse issues; development of five crisis centers to 10 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 provide acute treatment and coordination with community-based services; recipient of the 1998 Innovation in American Government Award for development of a unified Behavioral Health System; increased street outreach case-management assessment services and residential capacity resulting in a 45 percent decrease in the number of visibly homeless persons with behavioral health care needs from year 2000 to fiscal year 2001; creation of a model court that ensures families have access to treatment, rehabilitation, and support services in an effort to reduce the time that children remain in temporary placement while parents are detained; development of a good-neighbor policy pilot to improve communication, problem-solving, and efforts related to the siting and operation of community-based housing. The contract, which is the subject of the proposed ordinance, would, if approved by City Council, provide for a continued Commonwealth of Pennsylvania funding for calendar-year 2002, with 11 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 four additional annual review options in favor of the Commonwealth. Resolution of the financial issues discussed above will not impact the language of the contract. Like the prior contract, the proposed contract contemplates that the City will assume and retain risk of the program. Based on the same rationale as the initial contract, we believe the proposed contract requires City Council approval to secure the City's application to fund the program as of July 1, 2002. Before I take questions, I'd like to bring up Dr. Judy Dogin, the chief medical officer, to talk about some of the success stories that the program has experienced at this point in time.
That's fine. Before you do that, what I'd like for you to do -- 'cause we have some new members on City Council who are not familiar with the concept of CBH and the behavioral health program, and on of your testimony at the top, you sort of give an overview of how the programs are integrated. Can you just, in lay terms, tell us how that works. 12 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
Historically, the last 30, 35 years, the State and the federal government, through the State to the City, have provided the City with the funds to operate an Office of Mental Health and a coordinating office of drug and alcohol programs. The Office of Mental Health historically has worked primarily within community-based services. In other words, people who would be released from hospitals, particularly at that time State hospitals, come into the community, receive outpatient services. So the activity of the Office of Mental Health would be to provide those residential supports: To provide case management, to provide community, vocational services and community support services throughout the City. The Coordinating Office of Drug and Alcohol Programs is a single-county authority for all drug and alcohol programs in the county, and they provide everything from prevention services to intervention services, including supporting a number of recovery programs within the City. The key differences between both what 13 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 the Office of Mental Health does and CODAAP is that they provide services based on need as opposed to based on financial eligibility, which is a major difference in terms of how they function. The county offices also do not -- their population is not limited to the Medicaid population; it's limited to a much broader concept of need. CBH, on other hand, is Medicaid only so that -- and the services that they provide are only those services reimbursed by Medicaid. So that if someone is uninsured, CBH cannot pay for those services; the county office can. If they are uninsured and have drug and alcohol problems, the CODAAP Program, also through the State, funds a program called "Behavioral Health Special Initiative," which is for uninsured folks who have problems with addition. So there are several funding streams that come into this. By creating a system of care, our hope is that we can provide the services seamless in terms of the provider and the folks in the back room have to sort out the money for the State and 14 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 federal government to make sure that we have the right money funding the right service. So it's a fairly sophisticated activity to make sure that everyone gets a needed level of service, but the money is spent according to the guidelines that are set up by both the State and federal government. The Medicaid program CBH receives no 10 City dollars at all. The CODAAP and mental health program have about a 10 percent match. And if we wanted to get any deeper than what I've described to you, both the Deputy Commissioner for Mental Health, Mike Cavone, and the Deputy Commissioner for Substance Abuse Programs (CODAAP), Mark Bencivengo, are here.
Okay. Then we'll come back to the success stories. We haven't finished with you either.
I really -- because I think CBH is part of something that happened that was at its very beginning when you thought and started putting this idea together, the Mayor, the 15 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 former mayor, and the City Council had a different idea. And I think it was more or less to privatize the mental health services. And it was this lady here (pointing to Councilwoman Tasco) and people like me and community activists who were able to put together a coalition of Councilpeople and prevent the prioritization. And I remember that we had huge, huge, huge, huge arguments in hearings. I remember arguing over -- with David L. Cohen sitting right there in the chair, and we entered into sort of a little shouting match. But that it was a privatizing concept from the second floor. You didn't have a privatizing concept; it was presented to us. But then the political contributors and so on -- I don't want -- got into it, got into it.
And it's multi, multi millions of dollars that were involved in this.
And I remember -- because we came under a lot of pressure at that 16 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 time, but we were able to muster enough votes in Council to defeat that. And I'm glad that, you know, that now we're looking at it. And I read Dr. Arce's testimony and he says a -- he's happy to come here to testify about the successful implementation. So we didn't give it to the HMOs, we didn't give it to those individuals, and we kept it without being privatized, and it succeeded. And I think it's an example of what this Council can do when it puts its mind to it.
I think you're absolutely right, Councilman Ortiz, and I would also like to acknowledge Councilwoman Tasco because it was her leadership in the Health and Safety Committee?
Public Health and Human Services, sorry, that I think created the path for us to be able to be here today, because certainly, there was an awful lot of discussion as to why they should have an RFP and be out. And the major advantages have been that what would have been profit and would have paid a 17 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 profit company has now been replowed back into the system from any long variety of programs and services that we've had the ability to enhance and look at as opposed to paying profit to another entity. So I think all -- I thank you and I think all of the folks who have been involved both to manage the system, provide services to the system, and receive those services.
It also shows that we've been in a struggle with the second floor for a long time; it just didn't begin with, you know...
Well, I would like to first acknowledge that Councilman Rizzo has joined us; he's a member of this committee. But I think also you were telling me that this is one of only two programs of this nature in this country.
Actually, the only one that operates in this particular fashion, which means the government has total responsibility not only for the contract but also for the administrative -- direct administrative involvement in the services, which we hope gives us an ability 18 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 to integrate these services in a way that would not have been possible.
And that was the beauty of the whole concept, as you presented it to us in 1997, and we believe that we, because of the sensitivity of the people involved, would certainly be more caring about the clients and work to help them and not look at the bottom line in terms of profit. So the concept of piling the money back into the services was really very attractive to all of us.
I'd like to also acknowledge that while we are working in a system and creation of systems where there's been individual parts, it's not an easy task. We continue to struggle with that and continue to value quality and look at the quality issues. And our explanation often to the State is that budget -- that we don't want to be managed dollars and managed costs; we really want to look at the quality of care and hold people accountable for that quality, and use as a definition of quality, the definition being defined by people who 19 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 use those services and not just by administrators or bureaucrats, but the definition -- the people who receive the service get to help define whether that service is working for them and whether it's an effective service.
I am Judith Dogin, the chief medical officer of Community Behavioral Health of the Philadelphia Behavioral Health System. Councilwoman Tasco and Councilpersons, I'm very grateful to have the opportunity to share with you just a few of the success stories that demonstrate the privilege that the Behavioral Health System has had to partner not only with individuals and families but with our collaborators, the Department of Human Services, the justice system, the juvenile justice system, and the School District. I'm going to discuss five success 20 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 stories briefly with you this morning. The first is of an eight-year-old boy, who was noted to have significant behavioral health -- or behavioral difficulties in school, who was living in the kinship care with his grandmother as a result of losing both of his parents. He was a young man who was not able to function in school and whose grandmother sought behavioral health services. Originally, he had wraparound services, and through the evaluations that were provided, it was clear that he had some developmental delays, and actually, through collaboration with his pediatrician, it was discovered that he had very significant speech and language and hearing problems. This is a young man, through collaboration with his behavioral health providers, the School District, and his pediatricians, was enrolled in a specialized school with children with hearing impairments, speech and language difficulties, that could also provide for the behavioral health needs both of this boy and his family. He is now, we're pleased to say, able to 21 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 communicate through sign language, able to perform well in school -- his report card reveals grades of As and Bs. And most importantly, he is able to interact with his peers in a way that wasn't possible before I'd also like to share with you the story of a young woman, now years old, who, 9 unfortunately, was injured in a very critical 10 incident in which her mother was shot and killed, 11 and she was significantly injured, leaving her 12 having repetitive operations to repair 13 gastrointestinal system to allow her to be able to 14 eat and function. 15 She's a young woman who was 16 significantly depressed as a result of the loss of 17 her mother and several individuals in her family 18 being injured in the same incident. She was 19 repetitively psychiatrically hospitalized, was 20 placed in the custody of the Department of Human 21 Services as a result of the accident and loss, and is someone who now, we're very pleased to say, has been able to complete high school, is able to function on her own both physically and in the world, and was just able, with the support of 22 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 outpatient behavioral health services, to move into an apartment on her own, and is moving toward, through vocational support services, her first series of independently supported employment activities. And we're grateful to have been able to collaborate so closely with not only our pediatric colleagues but our Department of Human Services colleagues. I'd like to share with you also the story of a 12 year-to-date boy, who was diagnosed at 2 years to have very severe autism. He is a young boy who not only shied from social contact, would rarely speak, but remained also uninterested in interaction with the world. He is a young boy extraordinarily loved by his parents and his siblings who had a peculiar series of behaviors. This is a young boy who would pullet anything before him into his mouth, but really enjoyed ingesting and swallowing rubber bands. He's a young boy who required constant supervision of anyone around him. His parents would be up late into the evening, as he's not a 23 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 young boy who tended to go to bed early, supervising him.
He's also a young boy who, unfortunately, required abdominal surgery as a result of ingesting so many rubber bands that that he had a bolus of rubber bands in his stomach. With the assistance of our pediatric colleagues, a very caring family, and the efforts of the Behavioral Health System, this is a young boy who was placed in a very specialized residential treatment center for children with autism that focuses in on very intensive behavioral evaluation and training. This is a boy who, as a result of six months of very intensely 12-hour-a- day behavioral shaping and intervention, has been able to be moved to a transitional residential setting, where his parents are now reengaging and have learned the behavioral management on their own. And we're hoping to have this young boy returned to the care of his parents. I'd like to share with you also the story of a young woman who, unfortunately, as a result of involvement with drugs, was arrested and required, through mandated probation, to 24 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 participate in residential drug and alcohol treatment. She did so for the mandated period of time, transitioned to a lesser intense level of outpatient services, "intensive outpatient services," as we call them. And she is now a woman who has graduated from the program of residential treatment, serves as the head of her alumni group for this residential group, and is actually bringing back to the community through working in what is this forensic intensive recovery program that was the program that allowed her to be able to gain her successful treatment, but more important, her successful recovery and ability to function as someone who supports her peers in the community. And, lastly, I'd like to share with you the story of a middle-aged woman, a mother of four, who was very invested in the care of her children, despite the fact that she had been recurrently depressed from the time that she was a teenager to her early adulthood and actually to the present. She is a woman who, unfortunately, as a result of her depression and another disorder called "obsessive compulsive disorder," had gained 25 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 weight sufficiently that she was 400 pounds at the time she contacted the Behavioral Health System, desperate to be able to feel better and lose weight. She's a woman who let us know that nothing previously had really helped her be able to enter successful recovery. Through collaboration with our physical health partners, through working with in-home nursing care, and also through, most importantly, working with this woman's family and with the woman herself, we were able to arrange for her to be admitted to an inpatient unit that provides not only physical health but behavioral health-care services together. She has successfully moved from a weight of 400 pounds to just around 200, is able to function better physically, and her depression has been successfully treated. Most importantly, from her perspective and ours, she and her family were engaged in very aggressive and intensive family therapy, and she has returned home once again to be functional at home and to participate very differently with her family than prior to her admission. 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 I thank you for the opportunity to share with you these success stories.
Thank you very much. Are there any questions from members of the committee? Councilwoman Brown.
Thank you very much for your testimony and for the stories you shared. I am always curious to know, what are the linkages with the Philadelphia School District? I'd be particularly interested in knowing how those young people came to your attention.
If I might just repeat the question, the question was: Please define more what the collaboration is between the Behavioral Health System and the School District. We very actively collaborate in a variety of ways. There are identified members of the Behavioral Health System who are available to discuss with the School District any child and/or family who's been identified either through the arm of the School District that relates with behavioral 27 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 health services or the Office of Special Education. So there are individuals at a frontline individual-case basis that are available to begin to identify joint needs. In addition, at an administrative level, the policy and planning around services for youth often involves members of the School District. In fact, we have just completed an eight-month planning period that will allow us to create some specialized services for youth with educational and behavioral health needs, and that was done in collaboration with the School District.
And the young people that you've shared with us, how did they come to your attention; do you recall? especially since one of the young people was younger than a kindergartener.
In thinking about the children that I've just discussed with you, one of the children presented through his grandmother. The other simultaneously came to our attention by his parents as well as the School District.
Councilwoman, it's not 28 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 unusual for the referrals to come directly from the school. They maybe come directly into the 800-line to CBH, or someone may go into their neighborhood community center, and then those folks would call to talk to someone within the system. They also may come in through the delegate office, which is the crisis line that operates out of the Office of Mental Health. So there are any number of routes. I'd like to say that there's no wrong door to get into the system.
Finally, given what we are observing and witnessing with the School District, conversations and discussions are underway to ensure that those bridges are intact? In an attempt to be proactive, recognizing that it's difficult to get our arms around that.
In an attempt to be proactive, the City of Philadelphia did respond to the SRC's request for a proposal, and we were one of the groups that they identified to work with school safety and climate. Dr. Dogin was one of those that worked with us in putting that together, and Dr. Dogin and 29 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 Glen Taylor, who's also a part of the system, have worked with a series of providers, as Judy said, over the last eight months to set up as many alternatives and safety nets as we can as the School District continues towards their path in the fall.
Thank you. Managing Director, I like the success stories, but I think we have to -- in order to approve this ordinance, we have to put on the record, what is the current budget of Community Health Services?
Before she answers that, I want to come back to the School District so that we can stay in the same thought pattern.
What do you see maybe constraints or problems under the new system of governance with this SRC? 'Cause, you know, we find that we just somehow don't know who's in charge over there and what's in charge and how it's going to work. Do we see any negative impact on the program as it relates to the School District?
I think you just summarized what our concerns are, that we don't know -- I don't think they have yet clarified how the four or five different variations of the schools are going to work, so it's been hard for us to determine exactly what our role will be. In many ways, the rights of children with disabilities are protected under the IDA, the federal disability act for children and education, but on the other hand, many of our children will not be within that framework because the types of services that they need are maybe not that severe; what they need is more support, or the teachers need the support and the training to be able to deal more effectively in the classroom. We are attempting to stay very much on 31 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 the agenda for the SRC, and as we learn more about the various models, be prepared to support and work with them. As you know, if we take out the 70 schools that are going to be under a different model --
They may be under a different model, but at least we know that the other 200 or the other 175 schools remaining, that we will also continue our planning for them. But much of the activity that happens around behavioral health in school is based on relationships with principals and teachers, and one of the handicaps in being effective is sometimes not knowing where a principal will be, what school, and who those teachers will be. But as we all know, how effective a school can be is often how much of a team that principal can create with their teachers and how we can help them and the neighborhood and the families and youngster within that school get the service that they need and know the availability of 32 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 services. We've had excellent relationships with many principals, but then sometimes at that school, the principal changes and then you start all over again. So we are anxious to be as supportive as we can, both as a system and as a city as we can continue to work with the SRC.
Is it possible that those students in the 70 schools could be placed -- those services provided by a managed-care organization? And taken out of our system?
For those youngsters who are on Medicaid, there's no other provider, so they have to work through us at some level. Now, whether that independent school would say, We don't want the provider that you have working in that school, that will be a challenge for us because we believe we are working with providers to provide a high level of quality care, and if they in a provider that we don't believe meets that standard, then obviously, we need to have some further discussion. But we really don't know the impact that 33 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 they will have on the services in that school. They may tell us they don't want a behavioral health service in that school; then you begin to have two entitlements sort of clash because the child has an entitlement who has a medically diagnosed service, the child has an entitlement to that service, but if the school says, I don't want that service in my school, obviously, we have a problem.
So the parents have to be careful and monitor what goes on in the schools relative to the services. I mean, it's not just the parents who have children who might have problems, but it's all parents to be sure that those services are provided. I mean, that's one of the things that we have to be mindful of
I would recommend that parents be as vigilant as possible as to the kinds of services their children are being provided in school and what service are available for the child who may have be having any type of an adjustment problem.
Any there any more questions around the school issue before we go into 34 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 the dollars? (No further questions.)
That really shows you privatization -- and we're going one way in the school system, and we went one way with CBH, and obviously, CBH has been a success and not privatized. I think we should have the same success with the school and not be privatized. But go ahead, give me a...
Good morning, this is Ellen Steiker. I'm the director of financial policy for the Managing Director's Office. In answer to your question about the finances and budget of the HealthChoices Program, over the approximately five years that the program has been operating, our total revenue has been $1,834,958,000. Our expenditures have been $1,734,608,000, and our reserve for risk and contingency and reinvestment, otherwise known as our surplus, was $100,poo,000. Of that amount, $20 million, approximately, was reinvested in services in the 35 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 community --
Well, when we say "reinvested," could you explain that for the record, please.
"Reinvested" means we developed programs in cooperation and coordination with consumers and community groups under a protocol that the contract required of us, and we developed programs that met needs that weren't being met.
The bulk of that money actually went into to support the homeless street activities that we developed, so they paid for residential programs, street outreach. We put in dollars for an initiative for outreach in treatment services for the Asian community because there were not very many options for people with a variety of Asian language. We also created outreach teams and behavioral services specialized to the elderly and older adults on an outreach basis. We created -- there are 20 consultation 36 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 and education specialists in the schools -- we call them "C&Es" -- and they go into schools to provide support within an entire school environment for teachers and students within that school.
And in terms of citizens touched by these new programs that were the result of a surplus, how many clients are we talking about?
Just give me a tally if you can; I don't want it by specific area.
The Asian program touched about 5,000 people. The elderly program touched about 300 people. The C&E program, about 3,000 students over the course of the program. The homeless program has been one of the reasons we've been able to significantly reduce the number of people who are living on the street 'cause it created residential options for those programs. We can get you that data.
I'd like that to be given to the Chair, if you can provide it.
What about the other 80 million in surplus, where did that go to?
The other 80 million is in a fund, a risk and contingency and reserve fund. This was mandated by the contract that we maintain a fund, and it's there so that if there is an unexpected spike in utilization or some change in demand that wasn't foreseen when the rates were set, that there will be a reserve there to cover the services so that the General Fund won't experience any risk. Of the 80 million, this contract calls for 5 percent of revenue to be put aside in a restricted reserve fund, and there are certain requirements under which we can access that reserve fund, but that's 5 percent of revenue, or 25 million, that needs to be put aside in that fund. And of that 80 million, 25 of that is in that reserve fund.
So could you tell me what that fund comprises and how do you make access to it if you need to?
If there is what we call "adverse circumstances," then the City would 38 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 request from the Commonwealth permission to access those funds, and the contract says that that permission can't be unreasonably denied. So that if we needed that cash to pay our providers or to pay our costs of doing big business, we would be able to access those funds.
How many contract agencies are currently under the program?
And the average contract with these agencies is how much money?
The agencies are very different. In other words, the hospitals with inpatient units, the rate of reimbursement in hospitals is probably an average of 500 a day; while the reimbursement for outpatients services is for -- psychiatric outpatient service and the drug and alcohol outpatient service is $55 an hour. So it's hard to say there's an average since you -- and a residential treatment center is maybe $200 a day.
Do you have a list of these agencies and the contract, what they do, what service they provide, how many clients they have, 39 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 and they touch?
We can give you the name of the agency, the services they provide. The number of clients will fluctuate because people get to choose who they go to; we don't tell them.
If you can give that to the Chair, I'd really like to look at that.
We can do that. I want Ellen to work for you how the $100 million is spent. million went to 18 reinvestment, 25 is the 5 percent reserve. 19
Of the 100 million, 20 million went to reinvestment and 25 million went to the required reserve, as I just described, and the remainder is in a risk and contingency fund, and that fund, again, is there to make sure that we have the money to cover all of the services that 40 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 are provided. This is an entitlement program, so we need to cover all medically necessary services, and this reserve allows us the flexibility or the cushion so that the General Fund won't be at risk.
Are you prohibited from putting that fund to make money?
That fund is managed by the City Treasurer so that we're getting the same rate of return as all of the other City funds.
Just another point. Within the contract, the State requires us to have an insolvency reserve, which is equal to 60 days of unpaid claims, and these reserves are used to cover that insolvency reserve. Again, these are just overlapping requirements, but they're all there, again, to protect the State and the City from this contract causing deficits.
I just want to clarify because people sometimes hear the large numbers and think there can be more reinvestment. The reality is, we haven't been able to do reinvestment in the 41 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 last two years because all of the available dollars basically are within that insolvency fund, and that we can't spend those without permission of the State, and they require them to be there for availability, not to be spent for reinvestment.
You know, of those agencies that are under contract, what is the process of monitoring so that the level of service is maintained and that -- because one of the main issues in the years past that we had has been with community agencies misusing mental-health dollars, and we've had that out in the Latino community quite a lot, too much, too much so. How do we prevent that from happening? And what is the criteria that we use to make sure that the people that are supposed to be providing these services are people that are licensed and professionally competent to provide those services?
Let me have this answered in two ways; first with the CEO, Nancy Lucas, to talk about compliance and how do we measure that; and Dr. Dogin to talk about the quality assurance efforts to make sure that we're getting the quality 42 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 of service that we need.
Before you go into that, I want to come back to the reserve. Sorry. Councilman Mariano.
Councilwoman Tasco, I'm going to leave the hearings, and I want to leave a vote of yes for this ordinance, okay?
Let's go back to the reserve, and you talked about the treasurer having control over this reserve. I imagine that the reserve is an account where we earn interest.
Does the interest go into the old reserve, does it increase your reserve, or does the money go to the General Fund?
The interest was included. Over the course of the program, the funds have earned about $43 million of interest, and that interest has been included in the revenues. So of that $100 million of surplus, or reserves, you could say that 43 million of it was the interest. 43 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 We get to reinvest all of it; none of it goes to the General Fund.
And that is a requirement of the program under our contract.
But you have a hundred million you have to keep in reserve, right? So each year you earn interest, that means it's less money you have to take out of the program because the interest keeps the reserve to the $100 million.
Each year, we get a rate that is deemed to be actuarial sound. So the rate, including the interest, should be enough to cover the costs of the program.
But in essence, if that does -- and I'm not a money person; I'm taking this as an elementary, just thinking about it. If you -- if your budget is whatever and you don't have to put additional dollars into the reserve because you're making that up in the interest, the money that you would have put in the reserve, if it weren't making any interest, you keep as a 44 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 programmatic item and you still can provide additional services, right?
Well, it's the combination of the interest and the rate that has provided this program with both the operating costs that were required and also helped us develop the surplus. And I should say that the interest, you know, fluctuates, depending on the economic climate. There were years that we were earning 10 or $11 million of interest, you know, when interest rates were higher. This past year, the number was just about 6 million, and that again reflected the market conditions.
Yeah, one of the reasons why we gave that struggling to maintain this program and not privatize it was because we figured that there were monies that in a well- administered program, we could begin to enhance and then begin to really enlarge it without having increases even when we don't have increases from the State, that we're able to maintain the level and even approve it at that point. 45 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 So I'm very glad that we have that sort of situation, but I asked the other question in terms of the community agencies, and as a community that has gone through this, how do we maintain the level of services, the -- and, again, I go back to the testimony of Dr. Arce -- that have been identified by the Pennsylvania Department of Health as being seriously underserved both in quantity and quality of health-care services -- the African-American and Latino community. And we've had a history of that, and Estelle and I have had discussion over the years of how do we get this done so that we don't go through that sort of thing again? How do we maintain that?
Good morning, Councilpersons. I'm Nancy Lucas, the CEO of Community Behavioral Health. To address your question about monitoring, there are two separate types of monitoring that I want to talk to you about. The first is our credentialing process. For a provider to get into the network, the first step is, they must be licensed by the State. Now, depending on what service they 46 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 provide, that would determine who does the licensing, whether it's the Department of Public Health or the Department of Public Welfare.
-- as we would like it to be because it seems that anybody can be licensed by the State.
That's right, but that's only the first step. After you get licensed by the State, you must be enrolled in the medical assistance program. After those first two happen, then you apply to Community Behavioral Health, and we would go out and we will credential, and we have set standards that have been approved by the State that have been discussed with a good portion of our provider community, approved by the board, and we --
If somebody's licensed by the State, you can reject them?
Yes, we can. And in our annual reviews with the State over the course of the last five years, they have told us that they 47 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 like the standards that they have, and they've admitted that we're much tougher than they are. And occasionally they've admitted that they like the fact that we cannot use a provider that they feel that they have to license anyway. But we look at the staff qualifications, be it whether a mental health professional or a substance-abuse professional or a doctor or a psychologist, and see, do they really have the degree they say they have? Do they have the experience that they're required to have? We then look at the agency's policies and do they have a policy --
How do you check that, the qualifications and the degrees and so on?
For each person that they employ that performs a clinical service, the agency must have looked at the original certificate from, say, that college. They have a copy on it and they initial that they have seen the original.
Sometimes the agency, 48 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 as we found out, they just sign off and say yes, we have seen that, and...
We, in the last five years, have caught a few, and let me just jump here for a second to compliance. One of the things that we have is a hotline where people can call in about what they suspect is fraudulent activity. And when we get calls like that, we follow through. If necessary, we'll call the university and say, Did "so-and-so" ever get the degree? may we get a copy. We'll call the State licensing board and say, Is "so-and-so" licensed in this state? So we will pursue whatever complaints that we get, and because we have pursued them, we're now finding that the executive directors of their agencies do this first, and they will call us and say, I found out "so-and-so" was unlicensed, I have fired him, and I am going to give you back all of the money that I collected for the services he provided.
That would be a 49 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 first.
You mentioned about getting the money back from that provider, but what about the people that they cared for during that time that they were being cared for by an unlicensed person? What follow-up do you have with those folks?
When we've had difficulty with providers, we will pull a list internally, and we can pull a list from when we've paid claims and say, Who are all of the clients who have been there? We will personally call each one of them, explain the problem, and say, We'll help you find another place to go, here are the choices. Or, have you have you gone somewhere else yet? So we're, unfortunately, very used to doing this. In the year 2001, in our compliance program, we took back $400,000. We have a staff of four who do nothing but compliance: They run our paid claims, they go out to the agency, they go 50 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 through the agency's books, the clinical record, and say, We paid you $300 for this service on this date; do you have a clinical chart that shows that you served that client on that date? So it really is a match claim for claim.
Back to the credentialing. After we look at the staff qualifications and the agency policies, the next thing that we do is, we actually look at a sample of clinical charts and see, are there progress notes? is there a treatment plan? is there a discharge plan? are they following the plan that they have developed for the consumer? has the consumer signed off on it and agreed to it? And when we find deficiencies in those areas, we cite them, we ask for corrective action plans. And in the agencies that aren't extremely large, like the ones that are multi-site agencies, we actually offer technical assistance, and we have a small staff that goes out on a regular basis and does technical assistance with our providers. 51 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
We had a problem in the Latino community with some of the agencies classifying a lot of people as eligible for SSI in order to be able to make some collections along those lines when they were not. And I think that was discovered in some of the investigations that your organization did after it was formed. Do we still have that problem?
I can't say for sure whether or not it exists today, but I will tell you that we have suspicions of continuing fraudulent activity and excessive utilization for the purpose of generating revenue. As we speak, the Department of Public Welfare is sitting in CBH doing a record review of two agencies in the City because they believe that there is fraudulent activity. And the two agencies they're looking at, we've already examined them and cannot find anything, but it is their right to come in and do that check. We have a handful of providers that we have knocked out of our network because we have enough fraudulent activity, and we've pulled back enough money that they can't exist without all of 52 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 this excess revenue that they are not entitled to. So we will just continue our vigilance in areas where we might have suspicions and their revenue generation is out (indiscernible) or we get calls on the hotline.
The other half of the Councilman's question had to do, I think, more with quality. If Dr. Dogin wants to talk about the issues with quality assessment and --
Before you go, I'd like to just ask a couple of questions about the providers. You talked about the providers getting certified from the State and coming to you. Did you talk about the process for getting -- you talked about credentialing them, right, the various providers?
Okay. What is the diversity representation among the providers? 53 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
Unfortunately, I don't know the answer to that. It is something that we have committed ourselves to trying to discover. I can rattle off some agencies that I know and, you know, we know the hospitals are not minority-run on the whole.
No, I mean, what is the diversity among the providers you contract with?
I don't know the answer. I have my staff figuring that out as they continue site visits and credential each to take note of both the senior management of the agency and the board of directors when we can get that disclosed.
So when an agency applies to you, you don't distinguish whether they are minority, Asian; you just look at them and what their credentials are.
Because we have received concerns from some agencies, of course, 54 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 regarding the fact that a lot of providers who provide services and a lot of clients are of the Latino, African-American community, but the providers in those communities are limited. And so that is why we constantly ask that question because the question is constantly raised with us. So that, you know, we want diversity. When people want to be providers, we would like to know if there are -- those agencies are given access to the system.
As we create the list for -- Councilman Cohen [sic] asked that the names of the providers and the scope of services they provide. We will try to do that designation and give you our definition of how we define that. Obviously, there are a variety of issues associated with how you define the minority agency. With your permission, we will probably exclude hospitals from that list and probably institutions in general and go to community-based providers.
I think Councilwoman Donna Miller has a question about the Good Neighbor Program. 55 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
Good morning. I just want to ask a couple questions about the Good Neighbor Program. I know that -- I believe it was last year, there was a special session, I think, convened by Councilwoman Blackwell down in the caucus room. I don't know whether I have seen the actual final product of the Good Neighbor Policy, and I guess my bottom-line question is -- well, not having read the final Good Neighbor Policy, is this policy to be followed before or after there is community -- before or after the community becomes aware that, you know, some institution or agency has purchased a home in their district with three unrelated adults, etc. etc., leaving out the discriminatory ADA laws? But you know what's happening. I mean, it's happening to me again. You're familiar with what's happened in my district and other districts here in the City. And it just seems to be a little bit unfortunate that, you know, we start to take a look at -- use the Good Neighbor Policy, but it is always after the fact. What is supposed to happen prior to, but 56 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 not in a discriminatory fashion?
Good morning, Councilwoman. My name is Mike Cavone, Deputy Commissioner with Mental Health and Mental Retardation. The Good Neighbor policy, as you indicated, was instituted in the West Philadelphia area as a pilot because of the number of homes that were in that area, the number of complaints that we were receiving from some of the members of that community and those community groups. And the Behavioral Health System, the mental retardation system, and the Department of Human Services met for probably about a two-year period with a variety of community groups in that area. And really, the intent was to try and address issues of homes that might be in the community that may not be responded to either appropriately or timely. And what it did was brought a variety of the providers together with the community groups in more of a proactive approach, where they would meet on a monthly or a quarterly basis. If there were issues to be identified, the local neighbors would have contact folks from the provider organizations. 57 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 Those provider organizations committed to work among themselves to assure that there was a responsiveness that existed. As you indicated, I think, about a year ago, Estelle rolled that out in a presentation to all of the various members of City Council. And while I don't think it's been adopted from a policy perspective all the way, we've certainly encouraged all of our agencies to follow the tenets of that policy. The particular situation I think you're referring to, I've been in contact, and we've had staff in contact with members of your staff, and we've provided Kevin with a copy of the policy last week. And we're going to try and use that around some things. Certainly with respect to three-person homes, there is not a requirement on the agencies to go out and ask for permission to move into a particular neighborhood. When larger facilities are developed and there's requirements around zoning, then obviously, there's a different layer of public input that's required, and in some cases, zoning requirements and agencies having to go 58 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 through the Zoning Board. Three-persons home generally will go out prior to moving in, meet the immediate neighbors, try to provide points of contact for the immediate members in the event there are any concerns, folks are not taking care of their trash, parking inappropriately in other folks' spots on the street, and trying to develop that relationship -- begin the relationship before the actual move in, but continue that relationship on an ongoing basis.
But, you know, what happens is that people do not go out in advance, and I know that we can't treat the purchase of that home any different than the purchase of any other home. But what happens is that when no one contacts anybody and neighbors look up and they see maybe workmen, you know, adding some additions, maybe painting, and curiosity -- I mean, people stop; I stop all the time in my neighborhood and say hi, how you doing, who bought the house?
You know, just have a friendly conversation about what's going on. 59 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 And then when you have the workers -- I'm talking about, like, the painters or carpenters or whatever -- interpret to the neighbor who and what is moving in, then, you know, everything just breaks lose. I mean, wild rumors fly, they call us. In this last situation, the agency wrote Councilwoman Tasco a letter, but it's in my district, never indicating address, and it's just something that happened that's totally -- what happens in the neighborhood is that it's totally blown out of proportion, you have hundreds of people show up at a community hearing saying, Our lives are in danger, 'cause they don't have a clue, a real clue, about who's moving in, and there's just so much work that could really be decreased if people had the correct information in a timely fashion and stay within the ADA. I'm not trying to say we should discriminate, but people need to know -- there needs to be some type of a timeframe or encouragement even if the agencies would just call the Council offices and alert us, and maybe that we can work together on a way to go out in the 60 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 neighborhood rather than to have neighbors just pulling their hair out 'cause they think they're in danger. I mean, I went to one of the -- I didn't go to last week's meeting, but I was there the week before, and we've been in constant contact, and people actually think that their lives are in danger. And this man gets up and says, "Oh, my, you're putting me and my children's lives in danger," and I'm saying, "Damn, who's moving in here?" because we did not have the adequate information from Tabor Services.
We reached out to them, they sent a letter to Councilwoman Tasco. It was totally incorrect. Left the address out. And a whole bunch of stuff could have been avoided. I don't know in the Good Neighbor Policy whether it's encouraged that the service provider contact us. I mean, we know the neighborhoods, we're there all the time, we know the people.
And you are absolutely right about this situation, and I apologize. Tabor 61 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 is a relatively new provider of residential services.
They missed the mark, I believe, by a couple blocks, and in the vast majority of cases, the organization developing that home will give a courtesy call to the Councilperson to let them know what's coming in the area so that you're not blind-sided, and that's the protocol we've tried to follow, and we'll go back and redouble our efforts around that.
Well, I know that you're working with Steve in my office, and we've had a lot of -- I think we've had four or five meetings in the last couple weeks with the neighbors, and we're trying to really kind of cool people down.
And help them really understand what type of individuals are moving in, 'cause I think whoever described the potential residents was just totally uninformed and rumors just flew everywhere. 62 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165
I have actually offered, if it would be helpful to staff to come out to those meetings as well to help explain.
Okay. Well, I called your office the other week and left some messages because that's exactly what I wanted.
I wanted someone from the Office of Mental Health to go to the community meeting.
And we've worked with, you know, your office very closely with the other home that's on Ardleigh Street. And this is not far; it's pretty much in the same general visibility.
And some of the people that were at the Ardleigh Street meetings are now at (indiscernible) Street meetings. But I just wanted to make sure that -- and I am going the take the time to read the Good Neighbor Policy. And my first question was, is it to be used before or after? You know, before they 63 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 move in, after they move in, you know, after neighbors started yelling and screaming, or is there something we can do prior to?
I have a couple other quick questions. I'd like to know if we can get a list of the drug and alcohol facilities that CODAAP funds. And also, does BHS, just in terms of substance-abuse treatment, do you encourage or pay for outpatients only? or will you pay in and out? And does inpatient mean 28 days, or what does inpatient mean?
Councilwoman Miller, can we give you one list, which will indicate the agency, the provider agency, whether they're funded by CBH, OMH, or CODAAP all on one list so you'll be able to see? We'll also indicate on those lists of 64 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 services whether it's a mental health or a drug and alcohol service and the scope of that service. We'll try and come up with matrix --
So that you can have it all on one list rather than submitting different lists on you, with each list having some redundancy.
So the challenge will be to get one list with the right information.
That will be very helpful. I just want to go back to Councilwoman Miller's concern with the Good Neighbor Policy, and I know that you all are working very hard on it. I'd like to think that that is a part of your contract with these agencies because in looking at this last incident, maybe it was because this agency was new, or is new, in providing the service. As I look at the documentation that was provided to me, it seemed that all effort was made 65 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 to not inform us of what was going on.
And, yes, maybe we do not have to have permission to go put a group home of three unrelated clients in a community, and we understand that and respect that. However, what we do need to look at is the impact in the community, because what you do is, which we talked about early on when I came on, one community will get saturated with a number of group homes, and what happens is, they use the law to say that you can move -- that three unrelated people can move anywhere, fine. However, if you have three or four or five group homes in a one-or two-block radius, which I do in some parts of my district, that was the issue raised by the community people. If we know in advance prior to them even engaging, it helps us to work with the community, and we can say, one, this is what's happening in the community; once we get the list, we'll know where the group homes are. And we can help bridge the gap to work with the community in saying, This is a good program, this can operate. Because if 66 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 they find out, you're still going to go through all of that meeting and concern after the fact.
So if we could do it before the fact, if everybody's informed, we can inform the neighbors as to what's going on, then I think that will cut down on the complaints. And as I understand it, when Estelle explained -- made the presentation to us in the chambers, how it cut down on the turmoil in the West Philadelphia area, and so if there is a better working relationship with us those of us who are, you know, who represent the constituents, 'cause they're going to call us, they're not going to call you.
And I think it should be mandatory that they participate in the Good Neighbor Program, I really do. Because then that gives us all some input into what's going on in our district.
The other thing, through Estelle's efforts that we've been able to recently, is a database of all of the various social-service 67 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 agencies that do housing. So now when we're looking at that very issue that you've raised of what is in the particular area, we're not only looking at mental health and mental retardation, but the drug and alcohol programs, if DHS has anything in that area, if the Office of Emergency Shelter has anything in that area. And we'd be happy to come out and talk to the Council folks about what the area looks like. Also from a planning perspective that are there particular areas that you may be aware of that, as future development may happen, that we could target in to sort of avoid this. So are there areas where we're in a redevelopment mode where it would be appropriate to have a community home in that area. We'd like the opportunity to get out over the course of this year individually to meet with Council folks around that.
We want to, number one, show you what's in your area; and, number two, have 68 4/30/02 HEALTH/HUMAN SERVICES - BILL 020165 you give us some direction.
We had an opportunity to do that with Councilman Nutter a few weeks ago, and we found it helpful, and I think, hopefully, he found that helpful as well.
Speaking of Councilman Nutter, he is here with some questions. Are you ready? Yes, go ahead.
Excuse me, Councilman Nutter, could I just have the floor for one minute?