Bigger than a bread box, smaller than a refrigerator, I think.
I think over the course of a year, I think a hundred people is probably a reasonable number for the first year, given start-up issues.
And then hopefully there'll be several hundred 125 4/7/10 - WHOLE - BILL 100115, etc. after that?
I would hope that. I think the issue for us is -- and one of the things is, we're just getting a handle on the volume of people that are in -- that end up in detention who potentially would have a mental health problem. And so we're just at the point of sort of quantifying that.
So you might know the answer to the flip side of the question then, which is how many people of the currently incarcerated population are eligible for release into treatment programs?
It depends. Right now we -- if we're talking about addiction or mental health, because individuals who have --
Either, okay. So for addiction, for example, we have run a program called the Forensic Intensive Recovery Program. That program last year 126 4/7/10 - WHOLE - BILL 100115, etc. served 2,967 individuals in that program. And so those are individuals who have been identified in the Prison System who clearly have an addiction, have a history of addiction, meet the criteria from a criminal justice system in terms of their charges and so forth that we've been able to divert out of the City Prison System. On the mental health --
With respect to that, before you get to mental health, do you see the potential for growth of that program or are you sort of taking care of all the people you need to?
We're taking care of the numbers that we currently can handle given the resources and funding that we have.
Well, there is grant funding, but that grant funding hasn't expanded. So we're somewhat limited in terms of the number. 127 4/7/10 - WHOLE - BILL 100115, etc.
How much do you spend a day on people like that? In other words, if more people were eligible and we could divert them, obviously there would be resources in the Prison budget that would be available for that purpose.
Well, the number, if we're talking about -- most of these individuals are going to go into residential care once they are released. Residential care will cost somewhere between $75 and $200 a day. So for most people, initially it's going to cost more to our system than it would to incarcerate them. The savings really come more in the long term, because obviously these individuals don't stay in residential treatment forever.
With mental health, we're actually doing some really exciting work with the First Judicial District and developing Mental Health Court, and 128 4/7/10 - WHOLE - BILL 100115, etc. unlike most mental health courts in the country, which tend to be diversion mental health court, this is a mental health court that is really a reentry mental health court, meaning we're identifying people who are already incarcerated, who have already been adjudicated and looking -- and who clearly have a serious mental illness and have a certain type of charge, non-violent, so forth, that the prosecutor and the public defender, we all agree that these are individuals that would be better suited and better treated in a treatment setting than continue to be incarcerated, and we are working with them to divert individuals out of the Prison System. So that program has been up for the last year or so. We're increasing the numbers of individuals, and our hope is that over the next year, we'll have a steady increase of somewhere between 60 -- or a steady cohort of about 60 or a 129 4/7/10 - WHOLE - BILL 100115, etc. hundred people that we're serving at any given time.
Right now I think we have about 30 individuals that are in the Mental Health Court.
So this would be another up to 70 people that we're taking out of the Prison System on a sort of annual run rate basis?
At a given time. I would say cumulatively over a year, that would be somewhere between a hundred and 200. One of the limiting factors right now is that we use something called and it's sort of community treatment team, which is an evidence-based practice that we use to wrap services around individuals, and so that's sort of the limiting factor right now. 130 4/7/10 - WHOLE - BILL 100115, etc.
Have you found any difference in dealing with some of the stakeholders in getting these programs sort of utilized more with a new DA or maybe --
Are you having more cooperation with stakeholders in terms of getting people into these diversion programs?
Absolutely. I think the level of cooperation now between the criminal justice system and the behavioral health system is as good as I think it's probably ever been in the City. I think the District Attorney's Office, Public Defender's Office, the courts, Judge Woods-Skipper, who is leading Mental Health Court, I think everyone is, I think, solidly committed to this notion that people who need to be in jail need to be in jail and people who don't need to be in jail, we need to 131 4/7/10 - WHOLE - BILL 100115, etc. figure out a way to get them in an appropriate treatment center.
One final question. Are you involved at all in the Veterans Court program where there are mental health issues?
We've been invited to some of the early meetings. I know that there's some continued planning that's going on, and we anticipate that we'll be a part of that process when it's done.
Councilman Green, if you have more questions, we'll have to have a second go-around.
Yes, Madam Chair. I have no more questions. I just want to thank Dr. Evans for the great work of he and his team.
Thank you. 132 4/7/10 - WHOLE - BILL 100115, etc.
I just want to make sure that the two clocks are on the -- that's the Bill Green clock and then everyone else's clock, because it seems to always stall. When we hear the bell, we promptly adhere to the Chair.
I just want to know if we're on standard time or Bill 15 Green time. My point of information also had to do with the concepts of community courts, concepts of alternate courts and ask whether you have been in contact with Judge Frazier on her concept of connectivity court, and have you had any --
There seems to be a disconnect. There are a lot of 133 4/7/10 - WHOLE - BILL 100115, etc. people doing a lot of worthwhile things, and then you have CJAB and then you have those people who are actually in the courtrooms, practitioners that have done a lot of work, and I've reviewed a lot of their proposals, and I would think that there should be a connect to that, because I think we're coming to a point where all of these good ideas could be put in a matrix and us come up with a concept that does a couple of worthwhile things. One, reduces our budget obligation to criminal justice and to mental health, which combined represents close to the majority of the dollars spent. So if we threw in DHS, we throw in police, prisons, incarceration efforts, judicial efforts, we're talking about serious money, as Obama would say. But if we could all get together on this concept, and particularly where my point of information was, the criteria by which you assess risk, the criteria by which we can come together with a uniformed 134 4/7/10 - WHOLE - BILL 100115, etc. understanding of this person is a good risk, this person is a risk that is a little higher and therefore should or should not be eligible. Those concepts are at the building block of any successful diversionary court effort. So if we could all get together around a roundtable, irrespective of those who have official membership on CJAB versus those people who actually do it for a living or are impacted by it in their respective districts, could get together and maybe spend a half a day, lock the door, throw away the key and cell phones and figure this out, I think we could save the citizens of Philadelphia some serious money, come up with a product that actually stops recidivism, helps out some of the people who are doing it. Like the probation people have great ideas. The probation people know these folks better than you or I and can help in that process, but all of us are speaking different 135 4/7/10 - WHOLE - BILL 100115, etc. languages saying the same thing. So if we could kind of get that together, and I'll charge my colleague Bill Green, who is on CJAB, who is on CJAB, who made a commitment to being on CJAB, that he would look into that, that he shepherd that with you and other stakeholders, because right now we're moving at a good pace, but we need some coordination and leadership on this issue. Thank you for your kind clock and my point of information.
Councilwoman Brown, your light is on. Did you want to be recognized?
Thank you. Thank you very, very much. I wanted to follow up on the question around technical assistance 136 4/7/10 - WHOLE - BILL 100115, etc. that -- well, we know what that is. So internally how do you assist agencies who want to move to fit the criteria so that they can deliver services and become a provider?
Well, I think most of the providers who come to us for -- to be a part of the network come with the skills to deliver the service. They're trained as psychiatrists or psychologists. And so the issue really isn't the clinical skills to deliver the services. The issue tends to be more the administrative infrastructure that people need in order to operate their business in a managed care environment, which is a very different environment. So a lot of our technical assistance tends to be around helping people to put in place those systems that they need to function, and we've done a variety of things, from very formal things to more informal things. I've personally been involved in connecting providers with other providers 137 4/7/10 - WHOLE - BILL 100115, etc. who have established systems and infrastructure. We have staff at CBH in our Provider Relations that also provides feedback to providers on areas that they need to -- areas where they can improve their infrastructure. And obviously that's not limited to the administrative parts of their business. It is also -- we also do that relative to their service delivery too, to the extent that that's an issue.
Okay. Let's flip to the other end of that continuum where you may have providers who, based on your own internal monitoring, are no longer meeting criteria. What is your process or procedure for moving to discontinue that relationship, discontinue that contract?
That's a great question. The issue for me is that if we make those kind of decisions, they have to be transparent, they have to be fair, they have to be based on some empirical 138 4/7/10 - WHOLE - BILL 100115, etc. data, and, frankly, we have not had the level of data that I think is necessary to make those determinations that this provider should be a part of the network versus this provider shouldn't, unless someone is clearly providing really poor, egregious services, but beyond that kind of more extreme situation, I think it's more difficult. But this is an issue that we think is enormously important, and the reason that we've developed provider report cards, because it gives us an empirical, objective way to evaluate providers. As I mention in my testimony, we've now done that for two levels of care. We are rolling out this year probably another three or four, and what it allows us to do is a number of things. One is that we identify, again, in very empirical terms, areas where we evaluate providers; for example, on recidivism. We also look at things like complaints that they may have gotten. We look at a number of issues, and we 139 4/7/10 - WHOLE - BILL 100115, etc. provide a summary for each provider as to how they're doing. We not only do that, we give providers feedback in terms of where they are on a particular dimension relative to their others. And so, for example, take recidivism. You would receive back from us a report that would show, here is where you're at and here is where you're at in the continuum of other providers. So it gives people both objective information about how they're doing, but it also gives them information about how they're doing relative to their peers. Our plan and our intent is to then begin to use this data to make decisions about who we contract with, who we don't contract with, to the extent we're able to give some kind of incentive, those kinds of things.
I would suggest also that leads to some level of uniformity across the board when it comes to judgments about whether or not 140 4/7/10 - WHOLE - BILL 100115, etc. providers should be regranted the opportunity next time around or not. Would you agree?
So is that to suggest there's a monitoring unit at CBH that is in the business of reviewing provider contracts, looking to see if what's happening in real life is consistent with what is down on paper?
Yes. In fact, one of the problems that we have is I think we have too much monitoring right now. We have two or three units from CBH that do monitoring. We have units from the City side that do monitoring. And so one of the things that we've been doing for the last year or so is looking at how we integrate and come up with one standard way that we monitor providers. One, it's more efficient for us, it will save us resources, but it will also make it clearer to providers so that they're not 141 4/7/10 - WHOLE - BILL 100115, etc. getting mixed messages. So the short answer to your question is, yes, we have a fairly elaborate process of credentialing providers and then monitoring them through CBH. We have additional providers, but we're really trying to integrate that and make that a much more efficient process.
So if that is operating as you've just defined, when judgments are reached that a provider is no longer worthy of the granting opportunity with CBH, does it become a committee decision or is it a unilateral management decision?
A lot of people are involved in that kind of a decision, including if we take making decisions about who is going to be incentivized or not. I have a finance committee that, first of all, makes decisions about any issue that relates to a financial impact to the department. There are clinical 142 4/7/10 - WHOLE - BILL 100115, etc. staff that will do the monitoring who are supervised by other clinicians, and they will generate reports. And there are those of us in the senior management of the organization if we were to make a decision about eliminating a provider from the network that would also weigh in. So there are a lot of checks and balances throughout the system. There are no unilateral management decisions to have someone not be a part of the network.
I have additional questions, but the bell has rung, so I'll re-circle back when my time comes. Thank you, Madam President.
You're welcome. The Chair recognizes Councilwoman Sanchez.
Thank you, Madam President. 143 4/7/10 - WHOLE - BILL 100115, etc. Good afternoon.
I want to talk a little bit so that I better understand the financial structure of your department, because it's very unique because of its relationship with CBH. I notice that about half of your General Fund budget is for match related to your grant funding. Can you explain that structure for me?
Yes. You have $7.5 million in your General Fund that goes to the match, and according to your description, it's a grant-funded match required for residential services, emergency crisis intervention, day treatment and case management. So I want to understand that match.
Yeah. It's actually the entire 14 million. I think what you're looking at is a subset of the 144 4/7/10 - WHOLE - BILL 100115, etc. match.
Right. So of the City General Fund, 98 percent, say, are matched dollars. So what you're seeing is seven million of that million 9 that's matched, but the other 10 approximately seven million is also match 11 for other areas within the department. I 12 think you're looking specifically at 13 mental health. 14
Yeah. So the department receives State and federal grant dollars. Many of those funding streams require a certain amount of match from the department. For most of our dollars, it is a one-to-nine match. So for every dollar that we spend in the City General Fund, for those revenue streams we're able to draw down $9 to the City. 145 4/7/10 - WHOLE - BILL 100115, etc.
So why is the match from our General Fund and we don't require that as a match to our recipients of these grants?
We're granting this money out to some of these providers. I want to know at what point did we make the decision that the match was going to be a General Fund match versus an agency match for the dollars that we were giving them?
No. We pay the agencies to provide particular services. So we as a payer in turn purchase services from our providers with the dollars that we're able to generate.
I guess I'm trying to understand the formula. 146 4/7/10 - WHOLE - BILL 100115, etc. Because is that based on the fact that we've moved to fee for services versus --
No. Those are historical requirements for various State funding streams. So the State basically says, We will give you a certain amount of grant, but in return, you have to put some resources into the system.
That's for the county. And, fortunately, the county match is only one to nine. Some other funding streams have one to one.
I just wanted to understand that ratio, because then I want to be able to compare it to DHS and others as it relates to our matching kind of --
The matching works a little differently between DHS and Behavioral Health.
So we have a nine to one -- 147 4/7/10 - WHOLE - BILL 100115, etc.
-- as it relates to that. As you know, one of the areas -- and your office has tried to be extremely helpful with this -- has been, again, the need to provide multiple types of venues and support services for people in recovery. And, again, I'm all for the issue of recovery, but as the need grows through Mental Health Court, through community courts and all those issues and our wanting to move these types of services into the neighborhood, we create some other unintended consequences. So I want to get to those, which is the upsurge in recovery houses, many which are not funded or licensed by the City, and so, as you know, that has become an issue in the 34 and the zip code, some 23 of which I represent and some of which 24 Councilman DiCicco represents. If all of these other programs 148 4/7/10 - WHOLE - BILL 100115, etc. are successful, which we want them to be, how are we going to place some of these services throughout the City in a way that is more proactive than what has happened?
Absolutely. I mean, it's a complicated issue because, as you point out, most of the recovery houses in the City are not funded by us, are not controlled by us, we don't license them, we don't regulate them in my way, and people have the ability to do that because there isn't a license for a recovery house. Out of 160 recovery houses that we know about and have actually inspected, only 20 of those are those kind of providers. So I think from our standpoint, especially the attention that you've paid to this issue, I think what I would say to that is that from our 149 4/7/10 - WHOLE - BILL 100115, etc. standpoint, we're very cognizant of the issue and your concern about the community that you represent, and from our standpoint -- first of all, we don't have the dollars to expand, so it's kind of a moot issue, but to the extent that we would, those are the kind of conversations that we'd want to have with yourself and other stakeholders and representatives, to the extent that we were able to get those resources.
Can I get one more? And I'll circle back around, because I think -- I'm going to use the Bill Green clock. I think one of the issues becomes when there is opportunities where we can impact the placement, I think we need to figure out what other tools. I mean, obviously you know we've been trying to figure out whether there should be a recovery house, some sort of licensure and does the State preempt us and all those other things, but we need 150 4/7/10 - WHOLE - BILL 100115, etc. to get ahead of this, because we want those other systems to work and because this has become such a problem in certain parts of the City, and on the legislative side, we in Council need to know what tools we're going to give you so that this becomes a productive discussion and not the one that we have. Because now we're against the tide, because there's this anti-sentiment all over the place. So I think it's important that if we're not going to get something from the State, which it looks like they're not willing to do, what is it that we're going to be able to do at the City level to help you so that there's an understanding? Because I think the part that's the hardest for people to understand and for us to explain to constituents is, we can't -- we haven't regulated this and there's a need for it. I mean, if we shut down -- you're saying 161. The number is closer to 300. We probably know that. If we'd put four or 151 4/7/10 - WHOLE - BILL 100115, etc. five thousand people on the street, we'd have chaos. So we need to figure out what we're going to do, because Mental Health Court and Community Court are going to generate more.
Certainly. But I guess in terms of the things that we're already doing, the 160 that I mentioned are recovery houses that we've actually gone to, we've looked at, we've inspected. We actually rated them. What we've tried to do is because we don't have any regulatory authority over those entities, we've tried to be clear about what our standard is, because we have real clear standards for those that we fund around how they can operate and so forth. And I think they operate very well in the community. So what we've tried to do is, number one, encourage those who are not funded by us to adopt the standards and adhere to those standards. Number two, we've made 152 4/7/10 - WHOLE - BILL 100115, etc. available our training that we provide for our funded providers. We've opened that up to the other providers. And, number three, we've done technical assistance, particularly when we get a complaint about a provider that's not funded by us. We've used our resources to go out and work with those providers. So I think at this point, what we've tried to do is by influence get these providers to incorporate those standards, and I think we can continue to do that. My concern is the department not being put in a position where it's asked to do something that it's not resourced to do. So I think if we have a discussion about increased monitoring of those kinds of things, I think we also have to figure out how do we make sure that we're able to do that given the other demands that we have on our system.
And I 153 4/7/10 - WHOLE - BILL 100115, etc. guess the concern becomes other than L&I, the housing code piece, you know I'm going to have to legislate this somehow. I got to figure it out, because it's a problem. And I'm trying to figure out what's the best way that we do this on a local level where it is not an unfunded mandate. The State does it all the time to us, and we don't want to be irresponsible, but at the same time, we need to figure out whether it's a health code issue. And even your department, in terms of those clients, those people in the recovery houses are clients and somehow come through the CBH system as a fee for service.
Most of them do. I mean, there is a direct connection between a recovery house and your funded service providers.
Excuse me. The stenographer is just asking for a three-minute break, so if 154 4/7/10 - WHOLE - BILL 100115, etc. you don't mind. We'll break for five minutes. Thank you. (Short recess.)
Councilman Goode may have asked this question, but I have two questions, so short answers.
When CBH was organized, the purpose, I guess, was to provide services, but also keep the captured savings so that you could provide additional services. How well are you doing with that? And also has the State budget had any impact on the reserves you may have for that effort?
Sure. Yes. So the way CBH operates -- well, first of all, 155 4/7/10 - WHOLE - BILL 100115, etc. the contract is between the City of Philadelphia and the State of Pennsylvania. That's the contract. The City holds the financial risk. And so what CBH does is, it provides an administrative service for us, claims payment, utilization management, credentialing providers and so forth, but the City is at financial risk. So what happens is, on any given year, we're responsible for the entire behavioral health services for the entire Medicaid population in Philadelphia. It's about 428,000 people right now, probably go up to 450,000 by the end of the year. We get a set amount based on each person who is in Medicaid, and we're responsible for all of their behavioral healthcare. If at the end of the year we're able to manage our resources so that we have some savings, we then reinvest that back into our service system. If in any given year we're not able to manage all of those services within the amount that we get, 156 4/7/10 - WHOLE - BILL 100115, etc. we have a deficit and we would have to go into our reserve amount. So that's sort of the basic structure. So over the years since the program has been established, since the City has had the program, the City has had about five percent, what you might call, surplus or profit in managing the program. Half of that five percent has gone -- about half of that five percent has gone into reserves, the other half approximately into reinvestment. And there are reserves that we have to have by contract. So what we've been able to do with the amount that has gone into reinvestment is a variety of things. Number one, if you were here when Dainette Mintz was talking about the Mayor's initiative around reducing street homelessness, a big part of that strategy is making sure that there are behavioral health services for those individuals. We fund that. Because we didn't get any additional money. We took the surplus 157 4/7/10 - WHOLE - BILL 100115, etc. and used that to fund those services. So there are a variety of services with people in the criminal justice system and the homeless system, other kinds of community-based services that we use those dollars to fund and to supplement areas where we don't get adequate funding. For example, one of the areas that we spend $12 million a year on is the BHSI program for people who are uninsured who have an addiction. So that's typically the way we use it. And your second question had to do with how has the State's deficit or financial problems impacted us. Because we have to have a certain amount by contract in reserves -- it was previously defined as 45 to 75 claims days in reserve, part of our reserve. What the State did last year when there was -- when it was having its financial crisis was to reduce the contractual amount that we needed to have in reserve and then 158 4/7/10 - WHOLE - BILL 100115, etc. took back from programs a certain amount. The amount that we gave back to the State last year was $15 million.
Well, one of the impacts that it had is, as I mentioned, we use any surplus that we have in the program to supplement things that we think are underfunded or do programs that meet these kind of needs, like for the homeless. So essentially what that did was, it limited our ability to fund some of those programs.
But you were still able to provide your basic services to your clients?
The other 159 4/7/10 - WHOLE - BILL 100115, etc. one is, in your testimony you stated that 38 percent of CBH's non-profit providers have minority, female or disabled executive leadership and that 56 of the minority, women or disabled CBH providers experienced revenue increases of approximately million last year. How 9 did your office achieve these results? 10
Well, I think -- it 11 kind of goes back to kind of where we 12 spend the bulk of our resources. The 13 bulk of our resources are spent with 14 private non-profits, and we made a 15 commitment four years ago, five years ago 16 that, number one, we were going to 17 increase minority participation in our 18 provider network, retain those 19 individuals that came in and really tried 20 to ensure that they were viable, and a 21 couple of things that we've done. Number 22 one is, we've created a level playing 23 field, a very transparent process around 24 how one gets into the network. Now, 25 right now we're not accepting new people 160 4/7/10 - WHOLE - BILL 100115, etc. in the network for a variety of financial reasons, but for the first three or four years, we had a process that was much more transparent. People understood how to get into the network. The other thing we did was to procure most of our services through RFPs, which had not been done historically until we made that decision. I think providers appreciated it. All providers across the board, whether they were minority or not, appreciated the fact that the way we were identifying providers was through an open, competitive process. That started before the current contracting legislation that we were implementing. So I think that and the fact that we've been very intentional about having conversations with minority providers. We've met with -- in fact, my entire executive team has met with minority providers on several occasions. We have a task force; for example, an 161 4/7/10 - WHOLE - BILL 100115, etc. African Caribbean Task Force, that has identified issues unique to that immigrant community of color. So we've done a variety of things to both provide the support, but also keep the lines of communication open so that we understood some of the issues that people were dealing with.
Thank you very much, and you're doing a good job. We appreciate what you do.
I want to say that to Dainette. She's still with us. Thank you.
You're welcome. The Chair recognizes Councilwoman Sanchez.
Okay. I'm not going to be short. Dr. Evans and I have been working on this for a long time. It's important that we talk about 162 4/7/10 - WHOLE - BILL 100115, etc. this publicly and put it on the record. I guess where I'm trying to get to is, I want to get us to a place where we can close some of the loopholes that allow some of the bad recovery houses that really spoil it for everybody else so that we can cut down on some of them. So one of the issues is, we want communities to embrace this better, but we need to make sure if Neds (ph) or Wedge or anyone has a relationship with a recovery house, what I'm trying to get to is, is there a way that we can get our service providers to be more proactive around where they're getting their clients and where their clients live? Because I would think that our service providers understand the impact of where someone lives with their treatment program. And is there a way we can close that loop and make that one of the requirements?
I think that is an excellent suggestion and one, frankly, we 163 4/7/10 - WHOLE - BILL 100115, etc. had not considered in any formal way. I think it's a great suggestion. I think the way we've tried to do this up to now, as I mentioned, is to try to encourage people to adopt, but I think working with our provider network to say, Here are sort of the approved providers or recovery houses who have adopted these principles, strategies, whatever we agree to, I think is a good way to put pressure on those providers who are not providing a good service. So I think it's a great idea.
And I'd like to go even further and say to folks, for the providers, If you're getting five or six people or seven people, at one point there's a pattern of guys in one address. Can we require them to say, Okay, as part of this service, we're going to go out and do a site visit? I mean, I think part of it, we got to get our folks on the ground to help us.
We do that. I 164 4/7/10 - WHOLE - BILL 100115, etc. mean, the issue for us is again --
I think that they need to be part of the solution, and I think -- I don't want to give you more work that you're not funded for, but I think that if our providers are on the ground, I think we need to require that part of the service that they do once they get four or five people at one address, they should conduct a site visit. It should be part of their treatment plan. Can we do that? Is there any limitations?
Certainly we could put some things into place to try to help providers put in systems to do that. Again, I think it's a reasonable thing. I mean, one of the things that we've been saying to our providers very strongly is that you can -- and not all providers 165 4/7/10 - WHOLE - BILL 100115, etc. fall into this category, but you can no 3 longer have a program in the middle of a community and not have relationships with people in the community. You ought to be developing relationships with both informal and formal kind of supports. So I think in the context of that emphasis that we've had, I think, again, I think that's a very good solution.
If we can put that in next year's kind of requirements, that will go a long way of me being able to show some of these communities that we're looking to use whatever tools we have to get further cooperation. So I'd strongly like to encourage you to add that there. And then the other notion is -- and while this was in Councilman Clarke's area, it created even further problems in my district, when providers can kind of skirt some of the residential zoning requirements. So I need to put that on 166 4/7/10 - WHOLE - BILL 100115, etc. the record, only because, again, you take a good provider like Volunteers of America that does good work, but because of their rental structure, sets up a house in a deed-restricted area, and so they're now going to be able to place three people in this neighborhood, and you got the neighborhood in an uproar. I think if we want to ask neighborhoods to absorb some of this, we got to make sure that our providers don't use loopholes like that to move into neighborhoods. Because there's no way I'm going to be able to get anybody in Northwood to even entertain this, because they look at it as a provider skirting the system, and because we're subsidizing that provider, then we become party to the problem.
I think -- let me choose my words carefully here -- I think this is a real issue. I think there's a philosophical issue here. The issue is people with mental illness have a right to live in the community. 167 4/7/10 - WHOLE - BILL 100115, etc.
And I feel very strongly about that. One of the things that happens is if three college students or three guys who work construction decided that they wanted to move into a house, the community wouldn't oppose that. And the issue for me is that people and communities should not be able to keep people out of a community simply because they have an addiction, simply because they have a mental illness, because they decide to live together. I think that it's gotten to the point --
But if we want that level of cooperation, we can't have a corporate structure go around a loophole. If we want that community to embrace it --
I agree, to the extent that there's a loophole, but I think if three unrelated individuals who work construction can move into a house 168 4/7/10 - WHOLE - BILL 100115, etc. and rent the house, why can't three unrelated individuals who have a mental illness? I think that's issue that I have. To the extent that providers are doing something that is beyond what they are able to do, if there is a real deed restriction or if there is -- if now you're talking about four or ten people, I think that's a very different issue, and I think providers have to provide services in a way that's consistent with the law and regulation. But to the extent that people are operating legally, I have a real issue with denying people the opportunity to live in a community.
I totally agree with you, but when you set it up in a way that gets around -- it sets a bad taste for everything else. So here you have a community that otherwise might be willing to look at some of this, because I think people get it, but when you have that type of structure -- I think we need to tell our providers -- 169 4/7/10 - WHOLE - BILL 100115, etc. because, again, there's going to be a greater need in the community -- if you want to be a partner in the community, part of it is not using those types of loopholes, it sets up a bad taste, because now you have a situation where when we do need services and there is an opportunity, you're going to have an uproar. So we don't need to go there. I think we could do this -- because I think ultimately they're going to provide good services. People are not even going to know these people are there, but the tension that it caused going there now has unintended consequences that are going to go on for a long time.
I completely agree with that, and, in fact, we have been very clear and I think we've taken a very strong position that providers have to be not only in the community, but a part of the community and that -- in fact, we've created more problems for ourself, 170 4/7/10 - WHOLE - BILL 100115, etc. because one of the things that we require our providers to do when we do an RFP is to go out and get letters of support. We've had instances where providers have been in the community, successful, people loved them, they've gone out and gotten letters of support and because of reaching out, they then get opposition, when prior to that people were okay with them being there. So I think we have a very strong record on this issue of exactly what you're saying. Providers have to work collaboratively with the community, be as transparent as possible, but I also think -- and, frankly, I'm frustrated that there is no part of this city that a provider can put up any kind of program without some kind of community opposition. We have literally opposition to programs for deaf children. I mean, it's that bad at this point. And at some point, as has happened in other communities, what providers have done and 171 4/7/10 - WHOLE - BILL 100115, etc. what systems have done is say, We're going to take a stand under the Americans for Disability Act, and in every instance that I know, they've won. We've not done that here, and providers haven't done that because they don't want to leave a bad taste in people's mouth. But it's really gotten to the point where every single -- it doesn't matter what it is, it doesn't matter how benign it is, there's community opposition. And I think no one wants to see a person falling down drunk in the community. At the same time, those individuals need to be treated some place and at some point they need to recover and they need to be a part of a community and move on with their lives. And our ability to provide that service is getting increasingly difficult. And so I don't disagree with you. I think we have a track record of saying that this is important, but I think we need, as a city and as a city 172 4/7/10 - WHOLE - BILL 100115, etc. department, some help from our elected officials in saying and be willing to sit with us with community folks and say, There has to be a reasonable compromise here so that people who are part of this community can live in the community and the needs and concerns of the community are met.
No, I agree. That, again, under your administration has been a little bit different, but historically that has not been the relationship, and so we're fighting kind of this tidal wave of people feeling like they haven't had an input. And I know how difficult that is, clearly. And so, again, one of the things that I've said to the Administration is, we really got to map out where all these providers are, and so that when we make a hard choice that we are going to go against the community for a particular institution, that we have the data to back it up. But there are 173 4/7/10 - WHOLE - BILL 100115, etc. clearly areas of the City that have more than others, and that's easy for me to say because I don't need to absorb any more, I got more than my fair share, and I know how difficult that's going to be for my Council colleagues to absorb, but I think if there's a more proactive way and this is where departments have to break down their silos, where DHS and Office of Behavioral Health and OES, we start mapping this out in a more proactive way, we can start talking about this around certain neighborhoods and creating a more welcoming environment for some of this stuff, because these are their kids, too.
And it's very disheartening for me when I go to a meeting and people talk about these folks as if they're not our folks. And I take political heat because I said I'm not against recovery, this is a need. There's a correlation between the 174 4/7/10 - WHOLE - BILL 100115, etc. abundance and the need and why they're located where they're located, but if -- and that's why for me when people kind of work around rules, it becomes very difficult for me, because that is an area where we can say, Hey, if we're going to do this, we're going to do this above board versus working around it, because then it creates this bad feeling in the community that's more difficult. So I guess I'll end with, at least you're going to look at contractually how we can, again when a provider has more than six or seven people from one address, how that gets built into their contract, so at least we can say we've accomplished something and we're going to kind of move this. Another controversial issue, and it will be my last one, is around Prevention Point. It has been successful. I want to be more supportive of where we put them, but there has to be a commitment for additional resources for 175 4/7/10 - WHOLE - BILL 100115, etc. us to do that. I mean, I've tried to talk to Temple and some other locations. They've clearly outgrown that site, and they're not going to be able to get a bigger site unless they get more money. And if you want me to continue to take the heat for it, I need it properly funded so that we can move it somewhere where it's more appropriate.
Because I get those calls all the time. As the weather gets warmer, it becomes more visible. I think they're doing good work. I'll continue to defend them and support them, but they need to be appropriately funded so we can place them somewhere permanently.
Thank you. But you didn't commit to the additional resources. 176 4/7/10 - WHOLE - BILL 100115, etc.
I can't do that until I look at my budget. That would be irresponsible and I wouldn't want to do that.
You're welcome. Any other questions from members of the Committee? (No response.)
You've been very patient. The Committee will stand in recess until 2:30. Thank you. (Luncheon recess.)
Sorry for the wait. We are now expecting the Health Department to come up. Dr. Schwarz, please. 177 4/7/10 - WHOLE - BILL 100115, etc. (Witnesses approached the witness table.)
Councilwoman Tasco, members of City Council, I am Donald Schwarz, Health Commissioner for the City of Philadelphia. I am joined by Carmen Lemmo, the Deputy Commissioner for Finance for the Department of Public Health, and I want to thank you for this opportunity to present the Department of Public Health's Operating Budget request for Fiscal Year 2011, and I want to particularly say to City Council that this is National Public Health Week and hope that you and your staffs and colleagues will all feel welcomed tomorrow at a major event by the Department of Public Health and partners at the Reading Terminal Market open to 178 4/7/10 - WHOLE - BILL 100115, etc. the public between 11:00 a.m. and 2:00 p.m. looking at particular ways to use food to be healthy.
The Department's Fiscal Year 2011 budget request totals $361,467,455. 2 million in the Acute Care Hospital Tax Assessment Fund. Of the total budget, $43 million comes from City tax-supported funds. The Fiscal Year '11 General Fund budget represents a decrease of $3 million from the Fiscal Year '10 estimated obligations for the Health Department. The Fiscal Year '11 budget will support 1,027 full-time positions - 742 in the General Fund, 278 in the Grants Fund and seven in the Acute Care Hospital Assessment Fund. Of note beginning in Fiscal 179 4/7/10 - WHOLE - BILL 100115, etc. Year '11, the Employee Medical Evaluation Unit, or the MEU, will be moved to the Office of Human Resources for the City where it will be a better fit because of its integral role in employee hiring, employee leave and determination of fitness for duty, all processes which are managed by the Office of Human Resources. The Fiscal Year '11 budget will continue to support services basic to the Department of Public Health's ability to carry out its core mission to protect and promote the health of all Philadelphians and to provide a safety net for those most at risk. Some highlights from the past year. The Department received two competitive American Recovery and Reinvestment Act awards from the United States Centers for Disease Control and Prevention called Communities Putting Prevention to Work, one for obesity, nutrition and physical activity of $15 million and one for tobacco control and 180 4/7/10 - WHOLE - BILL 100115, etc. 4 million. Of note, of the large cities in the country, we are receiving the greatest amount per capita than any of those cities. The ARRA funds were awarded nationally to just 44 communities out of more than 200 that applied. The "tobacco control" dollars will allow us to work with employers and individuals to improve resources for smoking cessation and to explore regulatory and legislative interventions to reduce the very high rates of cigarette smoking in our city. The "obesity" dollars will help create the infrastructure that I spoke to this Council about just a few weeks ago. We will begin to develop new ways to bring healthier food choices to communities throughout the City, to work with the School District on improving food options for children, and with retailers and employers on reducing unhealthy food choices while promoting active, healthy living. I should note that both grants 181 4/7/10 - WHOLE - BILL 100115, etc. must be spent within two years and we plan to use money raised by the sugary drinks fee to continue the very important and necessary anti-obesity efforts. The Department's Division of Disease Control was awarded three new ARRA grants to enhance surveillance and prevention of selected communicable diseases. The Childhood Lead Poisoning Prevention Program is in the second and third years for two ARRA-funded grants that provide job training, evaluation and remediation of environmental health hazards in foster homes and in daycare centers. com, a website designed to raise awareness about the environmental, economic and health impacts of idling vehicles and to assist in the enforcement of Pennsylvania's new five-minute idling limit for diesel 182 4/7/10 - WHOLE - BILL 100115, etc. vehicles. Currently, Philadelphia does not meet national standards for ozone and fine particulate matter, in large part due to emissions from motor vehicles with vehicle idling a significant source of pollutants. Diesel exhaust contributes to increased cancer and asthma risk and can negatively affect reproductive, developmental, immune and nervous systems. The City's eight health centers provided almost 350,000 patient visits in Fiscal Year 2009. Thus far in Fiscal Year '10, we continue to see an increase in need for our services, with 15,000 additional visits compared to the first half of last fiscal year.
The health centers provide comprehensive primary care, prenatal care, dental care, family planning, podiatry and specialty care to nearly 90,000 patients per year, including nearly one-quarter of the City's uninsured population. The Department expanded dental 183 4/7/10 - WHOLE - BILL 100115, etc. services for children in its health centers by expanding "Kids Only" dental clinic sessions from two to four per week, increasing access to same-day appointments and making reminder phone calls to pediatric patients. The result was a percent increase in child dental 9 visits and a 12 percent increase in adult 10 dental visits. 11 When pandemic influenza A 12 (H1N1) vaccine became available in the 13 fall of 2009, the Philadelphia Department 14 of Public Health launched a comprehensive 15 program to distribute vaccine across the 16 City. S. Centers for Disease Control and 22 Prevention. The vaccine was distributed 23 through hospitals, healthcare providers, 24 schools, walk-in clinics, residential 25 facilities and other selected venues. Of 184 4/7/10 - WHOLE - BILL 100115, etc. particular note, more than 45,000 doses of vaccine were given in Philadelphia schools - public, private, parochial and charter. For the first time we have immunized children through schools in more than 30 years. There were more than 500 sites offering H1N1 flu vaccine in Philadelphia. Approximately 450,000 persons were immunized through the Department of Public Health's H1N1 vaccine program. Of note, vaccine is still available, so please tell all your constituents to come in and get immunized against H1N1. We are not over the H1N1 flu. The Department achieved a score of 99 out of 100 on the Centers for Disease Control and Prevention's assessment as part of its Cities Readiness Initiative. This is a CDC pilot project to help cities increase their capacity to deliver medicines and medical supplies during a large-scale public health emergency. Philadelphia's 185 4/7/10 - WHOLE - BILL 100115, etc. City Readiness Plan consists of detailed information on how we would conduct disease surveillance, environmental monitoring, forensic epidemiology, event response, public information and communication, dispensing, medical treatment and addressing special needs populations. All death reviews in the City have been centralized in the Office of the Medical Examiner. The Medical Examiner's Office, in collaboration with the Department of Behavioral Health and the Office of Supportive Housing, created the nation's first comprehensive Homeless Death Review process to identify opportunities for prevention of future deaths of homeless individuals. The review process includes both a weekly conference call designed to identify and close service gaps and a quarterly retrospective review of all homeless deaths. I am proud to tell you that we 186 4/7/10 - WHOLE - BILL 100115, etc. just received data from the first three months of this year, which shows a substantial decline in the number of homeless individuals who died in Philadelphia despite the severity of our winter. In 2009, the Department worked with Philadelphia chain restaurants to help them prepare for Philadelphia's new menu labeling law, which went into effect in its first phase in January 2010 and in its second phase on April 1st. The Department met with establishment owners and their staff to work on satisfying the requirements of the ordinance. Philadelphia's nutrition labeling ordinance is the most comprehensive ordinance of its kind in the nation. The law will help customers make informed nutritional choices when eating, promote greater awareness of nutrition, and encourage healthier eating in any chain venue. Minority contracting 187 4/7/10 - WHOLE - BILL 100115, etc. information was requested by Council, and the Department of Public Health continues its longstanding practice of contracting with minority and women-led agencies and businesses, both for-profit and particularly non-profit.
The Department is committed to contracting with these businesses and supporting the Administration's goal of percent 11 minority, women and disabled-owned 12 businesses participating in City 13 contracting. The Department of Public 14 Health's 2001 participation goal is 25 15 percent. 16 For Fiscal Year '10, the 17 Department has implemented several cost 18 savings measures and revenue increases. 19 I want to emphasize that these measures 20 were publicly vetted and are geared 21 toward preserving high-quality services. 22 Most significantly, in mid January 2010, 23 the Department began charging for 24 services in our eight health centers. 25 The initial cost to uninsured patients is 188 4/7/10 - WHOLE - BILL 100115, etc. $5. By the end of this fiscal year, there will be a sliding scale in place so that those with the least means to pay will be charged the least. To date, this has resulted in over $40,000 in revenue collected. It's about $49,000 as of yesterday, with no patient complaints received or any drop-off in the number of patients seeking services. Electronic health records have been shown to reduce medical errors and improve the quality of care, while maximizing financial and clinical efficiencies. Given these benefits, the federal incentives being offered, not to mention the threat of federal payment penalties for organizations without electronic health records by 2014, we decided two years ago to implement an electronic health record system and released a request for proposals in 2009. The implementation is scheduled to start this summer and continue for four years. Although we have not finalized the 189 4/7/10 - WHOLE - BILL 100115, etc. contract, the cost for full implementation will be about $22 million. I believe with the revenue-generation measure and cost-reduction steps we initiated in Fiscal Year '10, the Department of Public Health will retain our ability to provide the level of services needed to carry out our public health mission. Thank you for the opportunity to present testimony today. I will be happy to answer questions.
Thank you. Thank you for your testimony. I have a couple of questions and then I'll open to recognize other Councilmembers. Thank you for the good job you're doing. We appreciate it. Considering the recent passage of federal healthcare reform legislation, what impact will this new federal law have in Philadelphia and what steps are being taken to make the necessary adjustments? 190 4/7/10 - WHOLE - BILL 100115, etc.
Perhaps the greatest impact, which won't occur fully until after 2014, will be that the majority of people who are currently uninsured in Philadelphia will be insured. That will make a difference not just to the one-quarter of the uninsured who we see in our health centers, but to the three-quarters of people who are uninsured in the City who have, we believe, not great access to care at the moment and many people go to emergency rooms. I expect it may in fact increase visit rates in primary care, which is what we would like, preventive care, and reduce visits for hospitalization and emergency care. Immediately, right now, children are eligible up till age to 22 be covered under their parents' health 23 insurance. That will have an impact on 24 the City and the City workforce on every 25 part of the workforce, not just in the 191 4/7/10 - WHOLE - BILL 100115, etc. City but in private employers and others throughout the City, and hopefully it will have a measurable impact on the health of people between and 26, who 6 aren't currently mandated to be able to 7 have insurance under their parents' 8 policies, but that went into effect 9 immediately. 10 By the fall, there is a retiree 11 piece that goes into effect early that 12 says that for a health plan like the 13 City's, if a retiree has a very large 14 health claim, part of that health claim 15 will now be eligible to be paid directly 16 by the federal government. We will be 17 reimbursed. That is potentially a good 18 thing for Philadelphia, for large employers as well. The problem is, the total amount in that fund is capped at $5 billion for the nation. So there will be an application process. The regulations are not yet out from Health and Human Services. And it exemplifies for me what's going to happen between now and 192 4/7/10 - WHOLE - BILL 100115, etc. 2014 when we have full implementation. There are many steps in the 900-page Act, and many of those steps are regulatory steps. The Department of Health and Human Services' Secretary Sebelius has the authority and responsibility to develop that regulation. So we know by 2014, a lot more people will be insured. We know that benefit plans will be more standard. We know that it will have an impact on the cost of healthcare based on what's built into the Act. We don't know all the bells and whistles and how things will be done, so for us, the major part of Philadelphia's activity is to make sure that our legislators in Washington are educated about what can be done regulatorily, and we are actively speaking with people in Washington in regulatory offices, and I'm hopeful that we will have Philadelphians on committees that are put together to do some of regulation writing so that we're well 193 4/7/10 - WHOLE - BILL 100115, etc. represented and that the nation gets the best minds, because I think we have many really smart people when it comes to healthcare in Philadelphia who should have an active part in helping with the regulation.
The ability to carry a child on your insurance policy until 26, plus or minus a negative impact on the City?
It will increase our costs as a city, which is why I mention also the piece about retiree benefits. So that analysis is not complete yet, and the problem with the retiree benefit portion is, it's capped. So we don't know how many of those dollars we'll be eligible for, how quickly they'll go. But it will cost us more to insure the dependents of City workers through age if they wish to be 24 insured. It's not -- the first 25 estimates, as I understand it -- there 194 4/7/10 - WHOLE - BILL 100115, etc. may be people from Fiscal who know a lot more than I do, but my understanding is it's not a huge amount of money.
It's not? We can't afford any. That's a good thing. You have both sides to every issue, right?
Yeah. I hope for those children, dependents, who are living at home, it may mean less time away for their parents from the workplace as well. That's also a good thing.
Let me ask you a couple of questions. You talk about the increase in the -- 15 additional visits to the health centers, and certainly I guess the increase in the number of young people and adults to the dental clinic contributes to that. Are there any other factors that might contribute to the increase? 195 4/7/10 - WHOLE - BILL 100115, etc.
The demand for our services has gone up with the recession. It went up in 2008, it went up in 2009, and it's continuing to go up in 2010.
I think probably. There's a mix actually still of people who are both insured and uninsured coming as new patients. But clearly demand is on the way up. Remember, we've also seen some hospital closure in the City in the last year, and there's no indication that opening new primary care practices is very likely given the capital resources have been harmed in hospitals around the City. So I expect this trend will continue for a period of time.
On you talk about revenue-generating initiatives. How is the success in 196 4/7/10 - WHOLE - BILL 100115, etc. billing the State for those Medicare clients who use the facilities of the health centers?
We're doing great. We, remember, are a federally qualified look-alike, which means that we can, in a sense, bill twice. We receive dollars for capitation from Medicaid HMOs and Medicare HMOs, and then we're permitted to bill at our cost for service those same visits, Medicare and Medicaid, and receive a higher rate of reimbursement, minus the amount we received in capitation. And we have a, I think, very efficient billing operation in the Health Department. As you know, I worked before this at Children's Hospital and did billing for a very large physician practice there, and our folks I think do a terrific job. They've been looked at by outside agencies. I think they're doing quite well, and our reimbursement rates are favorable. The problem is, we have a lot of people who 197 4/7/10 - WHOLE - BILL 100115, etc. aren't insured, as well as those folks who are.
Do you have the ability to help an uninsured person apply for insurance?
We certainly do. Every health center has an office of people who help people get insurance if they're eligible. The problem is, it's multi-step, so you can't just come in and get insurance. You have to come in, bring documentation, fill an application, and we track that with people.
Your goal for Fiscal Year '11 in terms of DBE participation is percent. 25
Well, the goal before the Department revised it for '11 was ten percent. So the goal for the current year was less than ten percent, somewhere around eight percent, I believe.
No. I'm 18 actually talking about for the 19 Department. 20
The City 199 4/7/10 - WHOLE - BILL 100115, etc. only achieved 18 percent. A lot of that is due, however you want to view it, to the large fact that the Department of Health and Human Services did over a hundred million dollars in contracting, but less than four percent went to disadvantaged businesses, and that was done in a time when there was a citywide goal of 30 percent and there was a departmental goal of percent. 12 Why are we going to be able to 13 reach that goal next year versus not 14 having reached that goal in Fiscal Year 15 2008? 16
That's a great 17 and important question. Let me answer it 18 in two parts. First is why we haven't 19 reached it to date. As you may or may 20 not be aware, the Health Department -- 21 I'll answer for Health, and if you want, 22 I can also help with Human Services. 23 The Health Department has a 24 number of large contracts for specific 25 health-related activities, like 200 4/7/10 - WHOLE - BILL 100115, etc. laboratory tests. We have a lab in the City, but there are a number of laboratory tests that it just is not efficient for the City to process. We don't do enough of them. So we contract that out. There are limited number of vendors locally and nationally that are certified to collect insurance or bill 11 insurance companies for their service. They have to meet a standard. They have to have enough volume. They have to contract. So that limits with whom we can contract. Those are big vendors for us, large amounts of the vendor group. And so neither of the two big ones that we can contract with is either a minority, woman or disabled person-owned business.
I guess the question I'm really asking, Doctor, is, is there more capacity in terms of disadvantaged businesses? Is there more capacity to participate in Fiscal Year 201 4/7/10 - WHOLE - BILL 100115, etc. '11 than there was in Fiscal Year 2008?
That is part two, and yes. What I'm happy about is, we have two particularly large opportunities for contracting with for-profits, and in one case, we -- both contracts have now been officially posted. One for over $3 million, which is the largest, I think, single contract that the Health Department has, will go to a minority enterprise, and for the second one there's a guarantee of percent 14 participation by the vendor who received 15 the goal for minority and another 55 16 percent for women. 17
Okay. I 18 guess one of the last questions I'll ask 19 is, who set the goals for Fiscal Year 20 2008 and who set the goals for Fiscal 21 Year 2011? 22
I know that 2011 23 was a partnership between the Health 24 Department and the Office of Economic 25 Opportunity. And I don't know, because 202 4/7/10 - WHOLE - BILL 100115, etc. the goals for 2008 were set before I came.
Okay. I made this comment to every department. At the end of the day, the Office of Economic Opportunity does not do any contracting itself for the most part. They're not responsible for contracting. It's the procurement officials in the Procurement Department and/or procurement officials within each department. So at the end of the day, you know what goods and services you want to procure. You should be held responsible for finding out whether that capacity exists, and to some extent, you should set your own goal, and you should be held responsible for achieving your own goal. At the end of the day, when there are that amount of money going toward Health and Human Services and the constituency receiving those services in many cases are minorities and women, it does not make sense that Health and Human Services 203 4/7/10 - WHOLE - BILL 100115, etc. would do a hundred million dollars in contracting and that essentially 96 percent of that will go to businesses owned by white men. That's just wrong. Just one last example of where we're at or where we're not. You put out an RFP for electronic medical records?
The goals within the RFP? I can ask. I don't know off the top of my head.
Ten to 15 percent MBE, five or ten percent WBE. Who set those goals for that RFP?
One hundred 204 4/7/10 - WHOLE - BILL 100115, etc. percent minority participation.
That's a good question. This is a national RFP. This was to buy a software product and the installation. So it's one big award. There's opportunity within it for some subcontracting, depending on the size of the vendor, but in general, what we needed in order to ultimately be compliant with what are now federal regulations that we'll have to comply with meant that we had to use a national firm, and with that, I think the Department was concerned about who would bid, because we didn't know in advance. And we did a lot of work to go out and make sure that we had a well-represented applicant pool. There are really excellent minority contractors possible in that field, as can be seen, but I think we probably have the best -- I believe we have the best in the field, 205 4/7/10 - WHOLE - BILL 100115, etc. highest quality, wonderful vendor.
I guess my simple point is that there's no reason why the range couldn't have been to a 6 hundred percent, particularly if you do 7 the due diligence and find out what 8 capacity exists out there, and if there's 9 capacity to do a hundred percent, you 10 don't necessarily have to wait to see who 11 bids to find out. 12
And that 14 sends the message that, one, you 15 acknowledge the capacity exists out there 16 and, two, that people should not assume 17 that the person is not going to be a 18 prime contractor, but that a minority 19 firm is going to be a subcontractor. 20