COUNCIL OF THE CITY OF PHILADELPHIA2 COMMITTEE ON LEGISLATIVE OVERSIGHT3 Room 400, City Hall6 Philadelphia, Pennsylvania Wednesday, November, 17, 20107 11:20 a.m. PRESENT: COUNCILMAN JAMES KENNEY, CHAIR10 COUNCILMAN W. WILSON GOODE, JR. COUNCILMAN WILLIAM K. GREENLEE11 COUNCILMAN CURTIS JONES, JR. COUNCILWOMAN JOAN L. KRAJEWSKI12 RESOLUTION 100725 - Resolution authorizing City Council's Committee on Legislative14 Oversight to hold public hearings to investigate how the Risk Management Division15 of the Finance Department manages its relationships with Third Party Administrators16 who provide services for City employees who are injured on the job.17 - - -19 2
Good2 morning, ladies and gentlemen. This is3 the Committee on Legislative Oversight,4 which is dealing with Resolution 100725,5 which is authorizing City Council's6 Committee on Legislative Oversight to7 hold public hearings to investigate how8 the Risk Management Division of the9 Finance Department manages its10 relationships with Third Party11 Administrators who provide services for12 City employees who are injured on the13 job.14 This hearing is a result of a15 number of years of ongoing communications16 with the Finance Department, with Risk17 Management, either making inquiries as to18 how a company that's established in the19 City, that's been doing business in the20 City accesses this potential work with21 City employees on one hand and, on the22 other hand, why companies that have been23 involved in providing this service to24 City employees, out of the blue25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 sometimes, wind up being eliminated from2 the system, from the program, without3 prior notice, without any intercession on4 the part of Risk Management to find out5 what it is they are not happy about or6 what the Third Party Administrator is not7 happy about regarding the services8 provided by these companies, and on a few9 occasions, which we will discuss here10 today, these companies have basically11 been eliminated from the system with no12 notice, no warning, no intercession as13 far as how do we fix your issues, what14 you're doing or not doing right that15 we're not happy with, and in one16 circumstance, after three weeks of having17 no patients sent to them, the Business18 Manager for the company called Risk19 Management and was told that, by the way,20 you're out.21 We don't believe that that is22 the transparent way of doing this type of23 business and that we have longstanding24 companies in the City that have provided25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 services or want to provide services to2 City workers and, for some reason or3 another, cannot get an answer as to why4 they can't get in or how they got out.5 So initially we were going to6 go with the Administration first, but7 I've decided that I'd like to bring up8 some of the people who have complained to9 me or I've had interaction with to10 determine just exactly how it happens11 that you get on and just exactly how it12 happens that you get off and what happens13 in between that period of time. And when14 you cannot access the system, if you're a15 longstanding provider of such services,16 what are the factors involved in you not17 getting access to providing services to18 City workers.19 So this is kind of an20 investigative hearing. Hopefully it will21 bring some enlightenment to the process,22 but at some point in time, if we can't23 figure out what it is that goes on, there24 will be legislation that will be drafted25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 as a result of this hearing to determine2 how we fix this system and what exactly3 is going on with it.4 So we do not need a quorum5 today, because this is a hearing on a6 resolution, but in attendance is7 Councilman Goode, myself, Councilman8 Kenney as the Chair, Councilman Greenlee9 and Councilman Curtis Jones.10 I would like to ask11 representatives from Citywide Physical12 Therapy, Episcopal and Northeastern13 Occupational Medical Group, and Premier14 Comp Services, if they're here, could15 they please come forward.16 (Witnesses approached witness17 table.)18
You can use19 some of the other seats here and then20 we'll rotate. You can use some of the21 black seats.22 And just for matter of23 disclosure for the purposes of this24 hearing, I am an ex-officio member of the25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Board of Independence Blue Cross. I did2 not realize until the other day -- or I3 may have known in the past, but didn't4 realize that Blue Cross is an owner of5 CompServices. So I want to make sure6 that the record was clear that I'm7 disclosing that at this moment. And I8 don't see really any issue relative to my9 sitting on the Blue Cross Board, but I'd10 rather it be known for the record than to11 be discovered later on.12 What I would like the panel to13 do is to kind of talk about your company14 a little bit, the history of your15 company, what it is -- what services you16 do provide, how long you've been17 providing them, the number of employees18 you have in your company, where you're19 located and your experience either in20 trying to get into the system or having21 been removed from the system and what you22 think are the issues surrounding the23 current circumstances.24 So whoever would like to go25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 first.2 And if any other Councilmember3 has anything they'd like to start with.4 (No response.)5
We'll ask6 you to identify yourself for the record7 and, within those parameters, please8 proceed with your testimony. And please9 pull the microphone close to you.10
My name is John15 Mohollen. I'm from Citywide/Progress16 Physical Therapy, Director of17 Rehabilitation Services.18
Could you19 please, again, as I listed some of the --20 so for background information, how old21 the company is, what you provide, where22 you're located, what your relationship is23 with the City or has been with the City24 or is no longer with the City and what25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 your concerns are relative to the2 situation.3
13 My name is John Mohollen. 15 Real quick, please allow me a16 moment to give you a brief history of our17 operation. Citywide/Progress Physical18 Therapy was founded over ten years ago,19 has 75 employees in our eight20 Philadelphia and surrounding area21 locations. We provide physical,22 occupational, hand, aquatic therapy and23 free patient transportation to assist and24 rehabilitate hundreds of people daily25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 3 In January 2009, our Northeast4 clinic began providing physical,5 occupational and hand therapy services6 for injured City of Philadelphia7 employees who work in Northeast8 Philadelphia under the auspices of9 Premier Comp Solutions, LLC, contracted10 by the City of Philadelphia Department of11 Risk Management. Our Northeast clinic12 has employees who treat 250 patient13 visits a week. 17 By all accounts, the work18 performed by our physical and certified19 hand therapists with regard to injured20 City of Philadelphia workers exceeded the21 treatment guidelines and was reflected by22 referring three to five new patients per23 week from Premier Comp Solutions. Our24 working relationships with the panel25 10 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 physicians and case managers through2 non-compliance and weekly therapy updates3 was excellent, as were our efforts to4 control costs associated with providing5 these services. Since the services we6 were providing were so successful, hand7 and physical therapy referrals8 increasing, we needed to hire a second9 certified hand therapist and another10 driver to handle the increased11 transportation volume. 19 This success and commitment20 makes our recent termination as a panel21 provider for the City of Philadelphia22 even more confusing and frustrating. Our23 efforts received no notice -- I'm sorry;24 our offices received no notice whatsoever25 11 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 6 More upsetting is that the7 termination came to our attention only8 because we noticed the City employees9 referred to our facility dropped to zero10 over the course of the past month. As I11 am sure you are aware, this is no way to12 conduct business. 18 In closing, it is our hopes19 that the Committee on Legislative20 Oversight could assist us in getting21 answers as to why our contract was22 terminated without cause or merit. Based23 on our past success in providing these24 services, our clinical performances, the25 12 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 11 I'd like to thank Councilman12 Kenney and Councilwoman Krajewski for13 their guidance with this issue and14 members of the Committee for listening to15 my testimony. 20
So I21 understand your testimony, you were22 reading it, you indicate in your23 testimony that Premier Comp Services had24 never contacted you about the termination25 13 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 or the impending termination?2
Well, they did3 after three weeks of no -- three to four4 weeks of no patients. We noticed that5 the referrals were dramatically down.6
But did7 anyone from Premier Comp Services or Risk8 Management contact you and say, We're9 unhappy with your rate of return relative10 to the employee coming back to work,11 we're unhappy with the price that you're12 charging, we're unhappy with the services13 you're providing? I mean, was there any14 interaction, interface between Premier15 Comp Services, the administrator, and/or16 Risk Management Division?17
No19 complaints that you were aware of from20 employees that had come and received21 services?22
And no24 complaints from physicians who were25 14 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 referring?2
No. They were3 very happy with our outcomes. In fact,4 we took it a step further to build our5 relationship with Premier Comp in the6 fact that we flew out to Pittsburgh,7 tried to get an understanding of their8 systems, what we could do better to9 better serve the --10
Councilman15 Goode has -- we'll question you and then16 move down on those.17 So Councilman Goode, please.18
Thank you,19 Mr. Chairman.20 Thank you for your testimony.21 I agree this is no way for the City or a22 City contractor to do business, but I'm23 curious about a couple things you said in24 your testimony.25 15 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Can you explain how you2 discovered that you weren't receiving3 referrals and how long it took for you to4 discover you weren't receiving referrals5 and what portion of your business the6 referrals account for?7
It was four8 weeks basically without receiving any9 physical therapy -- I mean, any referrals10 from Premier Comp Solutions, and the11 average weekly referral was three to12 five, and over 250 visits, it's about13 25 to 30 percent of our business, overall14 business. More importantly, because we15 have two certified hand therapists, that16 represents over 50 percent of our visits17 a week.18
So it took19 you four weeks to discover there were no20 referrals?21 (Witness approached witness22 table.)23
Pull up one24 of those chairs and identify yourself for25 16 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the record.2
My name is3 Dean Hutchinson. I'm the Facility4 Director at 8019 Frankford Avenue,5 Citywide/Progress.6 The process he's discussing, it7 was over a four-week period that our8 referrals went from three to five a week9 to zero, and we in fact had set up a10 lunch to go out to Pittsburgh to meet11 with Premier Comps again. And we had12 called them to follow up on the lunch13 that we had set up and also asked what14 was going on, and that's when we were15 informed by Sharon, I think, that they16 just found out that both they and us had17 lost the contract.18
Premier Comp21 Solutions. So that's how it came about.22 They hadn't told us because I don't think23 they knew. But over three weeks, we got24 no patients, so we were calling to say,25 17 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Should we come out to have a lunch to2 meet with you guys if we're still with3 you, and that's when everyone found out4 what had happened.5
But6 Progress and Premier are two separate7 companies?8
Fine. All10 right. I think Councilman Goode's11 question was why did it take four weeks12 for you to determine that you weren't13 getting anybody. I mean, was that14 something that --15
It's really16 just for informational purposes, how long17 it took for you to figure it out, what18 was the drop-off. I mean, was it -- was19 there a minimal drop-off for the first20 three weeks, what was the drop-off, and21 then again, because it does account for22 25 percent of your business, I don't23 understand how you don't notice it right24 away.25 18 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
And I'll let --2 I noticed it after the first week. I3 spoke to Erica Kopcha, who has the4 relationship with the Case Manager,5 Sharon Kress, from Premier Comp6 Solutions. She had called up there. And7 then where they had said -- she'll have8 to speak to what was said, but it9 basically came back to me that, no,10 there's no problems, it's just slow.11 Then two more weeks went by, and that's12 when I said, Maybe we need to set up a13 lunch and go out, because obviously14 there's something wrong, and that's15 when -- after that period, that's when we16 had found out that we were --17
Of course,20 over -- yeah. It stopped the following21 week from three to five referrals to22 zero.23
Okay. Thank24 you.25 19 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
But your2 initial inquiry was that it was slow.3 The answer to your initial inquiry on the4 drop-off was a slowdown?5
My name is Erica10 Kopcha. I'm the Director of Hand Therapy11 Services at Progress Physical Therapy.12 There's variation from week to13 week depending on caseload, and we can14 expect there would be some type of15 variation. So there were periods where16 we were a little bit slower, and so we17 accounted that or attributed it to that18 for the first week to two weeks. After19 that, it was so dramatic that we knew20 that there was some issue and that there21 was something else that we needed to look22 into. At that point, I contacted Premier23 Comp Solutions to try to set up a lunch24 to see if we could sit down and discuss25 20 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 if there were any issues that we were2 having so we could address those issues,3 and at that point, that's when we were4 notified that we were dropped.5
Now, so6 it's not confusing, because there's a lot7 of CompServices and Premier,8 CompServices, Inc. is the Third Party9 Administrator for the City?10
When it16 comes to Progress, before we get to17 Premier, is there any complaint18 mechanism, I mean, from CompServices,19 Inc. or from the City, any contact of20 dissatisfaction or inquiries, utilization21 inquiries, pricing inquiries, the length22 of time a person is getting service? Is23 there any of that, what's going on,24 explain this particular case?25 21 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Premier Comp5 Solutions would regularly be in contact6 with our facility, weekly.7
You're not11 the Third Party Administrator for the12 City?13
No. I'm Third14 Party Physical Therapy Network.15 CompServices is the --16
So you have25 22 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 a subcontract with CSI?2
I have a contract3 with CSI and there's an addendum that was4 put into effect in August of 2008 by CSI5 on behalf of the City of Philadelphia.6
Okay. So7 any complaints or concerns would be your8 contact with Progress?9
Right. Progress10 is one of our network providers that's11 contracted with us, as are the other12 physical therapy providers in our network13 across the State of Pennsylvania.14
So if there15 were issues relative to Progress, you16 would be the person contacting or someone17 in your office --18
What24 contacts were there relative to25 23 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 dissatisfaction or complaints?2
Well, again, there3 were weekly progress reports that our4 company would supply to Premier on a5 weekly and ongoing basis. If there were6 specific issues, they would call us, talk7 specifically to the therapist, if there8 was issues related to length of patient9 care, explanations to how that care was10 utilized, and obviously we would make11 those needed changes on a case-by-case12 basis. But I think overall, we had very13 few of those kinds of interactions,14 because our care was exceptional.15
I would say maybe18 one to two times a month maybe we would19 get some feedback either through phone or20 e-mail.21
And how22 long did Progress provide services to23 City employees in this manner, how many24 years?25 24 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Thank6 you, Mr. Chairman.7 Just a basic question. You may8 have said this and I may have missed it.9 With Progress, who was the contract or10 the agreement with? Is it with --11
And what14 stipulations or terms were in there as15 far as notification or anything, or was16 there a timeframe in this? I mean, how17 long did the agreement -- was there a set18 timeframe?19
So when24 was it up?25 25 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
And was15 there anything in there about ending it16 if you didn't meet certain goals or17 anything like that?18
There was a19 60-day notification from either party20 that they could terminate the contract.21
No. We haven't24 been terminated from Premier Comp25 26 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Solutions. Premier Comp Solution was2 terminated from --3
So you were8 technically still under contract, but9 without any patients?10
Right, because11 Premier Comp Solutions lost the City12 contract.13
I'm17 getting confused here myself. But with18 Premier, did you -- what was your19 contract with the City? Kind of the same20 question I just asked.21
We had a Physical25 27 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Therapy Network contract.2
You have to3 pull the microphone close to you and pull4 it down so you're speaking directly into5 it.6
We've had a7 Physical Therapy Network contract with8 CompServices for approximately seven9 years. Two years ago -- well, in August10 of 2008, CSI contacted us to do a11 separate agreement on behalf of the City12 of Philadelphia at a much lower,13 discounted rate. We were giving14 CompServices a 17 and a half percent15 discount off the fee schedule for all of16 their clients statewide, but then they17 asked if we would go 30 percent below18 that, which approximately 47 percent19 below the fee schedule, if we wanted to20 get the City work, which meant21 approximately $95 a day. It was the best22 rate that we would ever -- I had to23 really think hard about this, because the24 margins were thin, but I thought about25 28 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the volume and the volume that could be2 given to the City providers, the physical3 therapy providers located in the City,4 and I felt that with the volume, it made5 sense to do the contract. So I entered6 into that contract in August of 2008.7
No. CompServices14 didn't terminate their contract. City of15 Philadelphia didn't terminate the16 addendum. In that contract with17 CompServices, it states that they can18 cancel for any reason with 90 days'19 notice, and if we breached the contract,20 they -- I actually attached the contract21 in the folder, so you have them. But22 also says that if we breach the contract,23 they can cancel immediately, but --24
But have25 29 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 you ever officially been told you were2 cancelled?3
No. They never4 cancelled it. They still use us. We5 still get referrals from CompServices,6 but City of Philadelphia removed us from7 the panels before notifying us.8 Okay. Here's what happened:9 We were blind-sided on October 12th. I10 received a phone call from Carrie Blouse11 from CompServices, and she said, I don't12 think anyone told you this, so I'm going13 to tell you this. The City removed you14 from the panels, their panels, your15 network, yesterday or last Thursday. We16 just found out about it from the City17 last Thursday. And this was a Tuesday,18 October 12th.19 And I said, What? I was20 blind-sided. What do you mean? I had21 never received even one complaint. I22 send monthly utilization reports,23 physical therapy utilization reports to24 the City. We saved the City $518,000 so25 30 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 far in 2009 below the fee schedule. We2 saved them another 509,000 already as of3 September 30th, which we projected to4 save them 650,000. There was never an5 e-mail or phone call or any6 dissatisfaction. Tell me why.7 She said, I really don't have8 an answer for you. You're going to have9 to contact Barry Scott from the City of10 Philadelphia.11 I said, Now, why would you12 reissue the panels and get them out there13 so I can't fix it? Like I felt I was14 already behind the eight ball. You call15 me after you reissue the panels. So the16 panels -- all our providers - Progress,17 Aquahab, Bustleton, Outreach - were18 removed from the panels, didn't give me19 an opportunity to discuss it with them so20 they would understand that they were21 going to lose the volume.22 I pleaded with her, because23 getting the City with this utilization24 control program they wanted required us25 31 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 to hire a full-time physical therapy2 director, which cost us $100,000 a year.3 It's one that I never had before and4 didn't hire until January of 2009.5 I said, Do you understand I6 have contracts with him? I can't just7 say, Hey, I don't need you anymore. I8 need some notice. The contract says -- I9 know you can cancel for any reason, but10 it says in the contract 90 days. You can11 cancel for any reason for 90 days, but12 you haven't done that.13 The answer was, We are not14 cancelling our contract with Premier Comp15 Solutions. The City is just not using16 you.17 I said, Well, geez, it's the18 same effect. You abruptly stopped using19 us. I would like to have a reason,20 something believable that I could convey21 to our network providers, Progress/Wide22 Physical Therapy and the others. And23 Carrie deferred me. She said that we did24 an excellent job, CSI valued their25 32 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 relationship with Premier Comp, that I2 had to respect the fact that the City of3 Philadelphia was their client and they4 had to follow their directives, and if I5 wanted answers, I had to contact Barry6 Scott.7
The8 impression that I've gotten in my9 conversations and staff conversations in10 my own with various people in the11 Administration is that CompServices, Inc.12 was contracted and hired to kind of be13 the clearinghouse for all this, that they14 were the ones making the decisions --15
-- on17 whether or not a company came on board or18 a company left, and it kind of took the19 City kind of out of the decision-making20 process directly, because they didn't21 want to make it look like they were being22 favorable to one person or another, one23 company or another. So this kind of24 generic CompServices, Inc. would make25 33 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 decisions to bring people in or let2 people go, just without any influence3 from the City.4 That's not the impression I'm5 getting from your testimony, and, that6 is, that CompServices is telling you,7 Hey, look, we really don't have any8 complaints with you, we've been told by9 the City you got to go.10
We're not13 going to send you any more.14 So my concern has been and the15 reasons for this hearing is that, is it16 CompServices, Inc. that's making the17 decisions on adding a company to a panel18 or removing them, or is it the City19 telling CompServices who they want on and20 who they want off?21
I haven't been22 able to get a straight answer on that23 and -- I believed what Carrie told me at24 the time, but I had a subsequent25 34 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 conversation with her that said, Well,2 that's not entirely true. So I guess I'm3 here today to find out what the answer4 is.5
Well, it's not8 entirely true that it was the City's9 decision. First, I wanted to know why10 the decision was made. When I got with11 Barry, when I talked to Barry, Barry12 said, I'm so sorry we handled things this13 way. It was so inappropriate for us to14 do that. You've done a great job.15 I said, Okay, you're sorry, but16 we're losing the business. What did we17 do wrong? I would like to know.18 He said, You didn't do anything19 wrong.20 Okay. Did any of our providers21 do anything wrong?22 No.23 Okay. Why did we lose the24 business?25 35 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Well, we just decided to -- we2 wanted to have direct relationships with3 the providers.4 And I said, You wanted to5 contact them directly?6 And he said, Yes.7 I said, Well, in our contract8 with you, it stipulates that you have the9 ability to contact directly our10 providers.11
Contact. They14 wanted the ability to call up our15 providers if they wanted to.16 I said, You have that ability.17 It's in the addendum. And you'll see the18 e-mails. I forwarded him the addendum.19 And this is the reason why I didn't20 contact all of them right away, because I21 thought I could fix this. I thought22 maybe there was a misunderstanding with23 Barry, because he thought he could not24 contact our providers directly, and I'll25 36 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 just show him, here's the contract. For2 two years you never even attempted to3 contact any of our providers directly,4 but if you want to now.5 So I asked him, Have you ever6 tried to contact one of our providers and7 they didn't want to talk with you?8 He said, No.9 Okay.10
But my11 issue is -- and we'll get to that12 question when the City's portion of the13 testimony comes -- is that I didn't think14 that was -- I thought that the purpose15 for hiring CompServices, Inc. was to get16 the City out of that contact, that17 CompServices, Inc. would be the18 administrator that would have the19 interaction, have the contact, make the20 complaints, do the remediation or let the21 person go -- or let the company go. And22 I still don't understand yet what23 CompServices, Inc.'s role in this whole24 process is, if in fact the City needs to25 37 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 contact providers directly.2
Exactly my point.3 When we got the contract, I initially got4 the contract, that was the first time in5 August of 2008 that I met -- well,6 actually, in January of 2009 was the7 first time I met with Barry Scott, and8 today is the second time I'm seeing him9 today. So I met with him at the10 recommendation of CompServices. He11 selected Premier Comp Solutions. We gave12 him a list of our providers in the City.13 He selected the four - Progress,14 Bustleton, Outreach and Aquahab. He15 selected them. I did not. I just gave16 him a list.17 Starting February 1st, they18 started utilizing us, and then I was told19 by CSI -- I was first told that I would20 have to attend quarterly meetings with21 the City when they went over physical22 therapy utilization. And then I was23 told, no, Comp Services will have all24 those meetings; if they need me, they25 38 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 will get in touch with me. But I was to2 submit monthly physical therapy3 utilization reports and savings reports4 to CompServices, and they assured me they5 would have the meetings and convey all6 the information. I received an e-mail7 saying, You are not to have any direct8 communication with the City, we are your9 sole contact. The only issue is, I sent10 these physical therapy utilization11 reports every month, and I never even got12 a reply like, Hey, thanks; Hey, we like13 the report. So I would call and say, I14 haven't received any feedback. Don't you15 think they're great, or anything?16 Oh, no news is good news. The17 City is happy with you. You'll hear from18 us, believe me, if anything is wrong.19 I believed that. For months --20 for two years, every single month I21 faithfully sent these savings reports,22 faithfully sent these utilization23 reports. Our physical therapy24 director -- and you'll see, they're 2025 39 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 and 18 pages a piece -- made2 recommendations to file utilization3 reviews with the Bureau, and no one from4 CSI ever did it. So I'm not even sure5 why we were doing what we were doing and6 giving it to them, because they weren't7 doing anything with our recommendations.8 So when you're asking me this9 question, I don't know whose role was10 whose.11
Thank you,17 Mr. Chairman.18 Does your contract have a19 specific dollar value?20
No. Actually, I21 should back up a little bit. We're a22 certified woman-owned business and a23 certified disadvantaged business.24
I'm going25 40 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 there.2
But does5 your contract have a specific dollar6 value?7
They never gave me8 a copy of the contract that they did with9 the City. They utilized us as a WBE, I10 understand.11
I'm not25 41 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 interested in that.2
There's no7 commitment in terms of dollars related to8 your contract?9
In CSI's15 proposal, were you guaranteed anything16 specifically in terms of commitment?17
I never was given18 a copy. I was asked for my certificate19 and they wanted to utilize my network for20 the City contract.21
But they22 never said that you would get a23 percentage of the business?24
Well, I was25 42 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 contacted by the Office of Economic2 Opportunity, which is odd, about two3 months ago and they wanted to make sure I4 was getting this business, because I was5 listed as a subcontractor on CSI's6 contract with the City, and they asked me7 the billed dollar amount at that time,8 which was like August or something they9 contacted me, and I had to run a report10 for them and I gave it to them.11
We received direct18 payments from CSI and we pay the19 providers.20
But you had21 no specific dollar commitment from CSI?22
There might have23 been one in their contract with you, but24 I've never seen it.25 43 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
No. I'm2 talking about in your contract, you had3 no dollar commitment from CSI?4
I just12 wanted to know if they happen to know the13 names of the PT providers that the City14 is utilizing in place of your network15 providers.16
Do you18 happen to know why the City selected19 these providers?20
La Fortaleza21 Physical Therapy has always been on the22 panel and they remain on the panel today.23 I asked Barry why they were on and we're24 off. Because they're a minority-owned25 44 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 business and we're a woman-owned2 business. I just wondered what was the3 difference.4 He just said, No reason.5 They remained on. So La6 Fortaleza still has it. NovaCare, who7 was removed from the panel two years ago,8 which is why we were -- we were9 approached two years ago because we were10 told that NovaCare was over-utilizing the11 physical therapy and they wanted an12 alternative to NovaCare. That's why the13 City wanted CSI to do a contract with us.14 So it was very surprising to me when I15 found out that NovaCare, the one that16 they dumped two years ago, was put back17 on the panel.18
I don't23 even care about the "dumped" part. When24 you say "they," is it CSI or the City?25 45 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
It was both of2 them. When I met with CSI, NovaCare had3 over-utilized -- and I'm just quoting4 from what Barry told me. I guess they5 had tried to give some box seats to the6 City people, and that's in violation of7 the vendor code, and then they were8 removed from the panel, and then Dan9 Bradley, their CEO, went to the Mayor to10 try to get --11
So he went to the18 Mayor, and Barry was upset because Dan19 Bradley had gone over his head. So Barry20 had told me he didn't want anything to do21 with NovaCare, and as long as we could22 save him -- and I had estimated at the23 time that I could save the City a half a24 million dollars a year, and I was praying25 46 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 I could meet that goal, and I did. And2 he said as long as I could save that kind3 of money for the City, I don't have to4 worry, I'll always have a contract -- I5 mean, I'll always get the work. I don't6 have to worry about NovaCare giving box7 seats to people at CSI or anybody like8 that. I don't have to worry about that.9
But10 Councilwoman Krajewski's question was who11 else --12
One17 more question. Is there any reason you18 can possibly think of which caused the19 City to abruptly remove you from their20 service?21
I'd24 like to know.25 47 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
I would love to2 know, and I'm hoping that after they3 testify, I will find some answers. I4 have asked everybody. I've asked5 Barry -- I mean, I've been given answers6 that don't make sense.7
Well,8 this isn't the first time; there are9 others too that had the same problem.10
Well, I guess11 others are having the same problem, but12 the problem -- Barry told me he wanted to13 have direct contact. That was the reason14 he gave me. That's the reason. But he15 had direct contact in the contract. It16 stipulated it. And I thought by17 e-mailing him the contract, it was going18 to fix this whole thing. He'd say, I'm19 sorry for the mistake, and put you back20 on. Then he --21
Is22 there any way we could find out,23 Mr. Chairman?24
Find out?25 48 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 I'm sorry.2
Why? What4 we did today was, we had these folks come5 testify first to kind of frame the6 problem, and the Administration is here7 to respond, hopefully respond, to the8 issues that are raised.9
I've sent numerous12 e-mails that I have not received any13 response on. So I have tried ad nauseam14 to find out the reason. I wish I could15 answer your question, and I hope today to16 find out.17
What I'd18 like to do is just kind of finish up this19 particular panel.20 And just reiterate again, how21 many employees do you have in your22 facility?23
Twenty-five24 people in our Northeast location.25 49 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
They're the2 folks who were affected potentially by3 the loss of the City contract?4
And you6 have locations other than Northeast7 Philly?8
Yes, we do. We9 have eight locations. Yes, we have eight10 locations.11
And so was12 the only facility being utilized by the13 City the Northeast location?14
We had a hand18 therapist, but due to the volume, we19 brought on a second hand therapist20 that --21
What are22 some of the injuries that require a hand23 therapist?24 Please identify yourself for25 50 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the record.2
My name is Erica3 Kopcha. I'm Director of the Hand Therapy4 Program at Progress Physical Therapy.5 Certified hand therapists6 require a specialty certification in7 order to manage complex hand injuries and8 upper extremity issues that can occur9 whether on the job or through various10 other types of trauma. Typical physical11 therapists are unable to perform these12 tasks. Our assessment abilities and13 skill-set is unique to those injuries.14
What are15 the typical injuries that require hand16 therapy?17
Hand fractures,18 tendon injuries, nerve injuries, trauma,19 gunshot wounds, car accidents, oftentimes20 with City workers restraining prisoners21 with our corrections officers, subduing22 suspects on the street for our police23 officers, things of that nature.24
And are you25 51 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 aware -- let me go back to Premier again.2 Are you aware of the current --3 I assume this is the current panel that4 was handed up?5
I have asked for a6 copy of that panel from CSI and from the7 City and I have not been given it. It's8 like a secret thing.9
So10 La Fortaleza, two locations, and then11 nine NovaCare locations.12
All right.17 Is there anything else that you would18 like to add? That's fine. If not, I'd19 like to bring -- oh, Councilman Greenlee.20
Just real21 quick. Thank you, Mr. Chairman.22 Again, for Premier, just so I'm23 real clear on this, all your contacts24 with either CompServices or the City on25 52 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 this matter of being taken off the panel2 has all been verbal? Have you ever3 gotten anything in writing?4
No, not at all.9 And I've sent the savings reports, I've10 sent the utilization reports, I've sent11 copies of the contract. I've said, Look,12 can you please at least adhere to the 9013 days' notice? No response.14 Now, they did pick up -- during15 that first week, they picked up the phone16 and called me. They would never respond17 to an e-mail, because that would18 constitute a paper trail. So they picked19 up the phone and they called me. And no20 one wants to -- like CSI is saying, We're21 not privy to the reason. The City is22 saying, I take -- Barry did say, I take23 full responsibility. This is not -- CSI24 is not to blame.25 53 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 I said, All right, but how did2 NovaCare end up back on the panel when3 they got thrown off two years ago for4 giving gifts -- trying to give gifts to5 the City? And I wanted to know this:6 What analysis did you do? Like did7 NovaCare come in and say, Hey, we can8 save you X amount of dollars? What did9 they tell you? What did they try to sell10 you?11
I just12 want to be clear. Everything has been13 verbal, right? There's been no --14
That's right. In18 fact, I got wind of this hearing today on19 Monday, and I sent e-mails out to them,20 because I didn't know what it was about.21 I didn't find out until 4:30 yesterday22 that this hearing was taking place. I23 was literally up until 3:30 in the24 morning in Pittsburgh, hopped a flight to25 54 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Philadelphia this morning and slept two2 hours. I'm just saying that I tried on3 Monday --4
Sounds5 like you've been drinking some coffee,6 too.7
I wish. I haven't8 had coffee or I'd be talking a mile9 minute more faster than I am right now.10 But what I'm saying is, I11 tried. I sent an e-mail to them on12 Monday saying, Hey, I've gotten wind from13 one of my network providers there might14 be a hearing. No response. It's like15 it's secret.16
All17 right. Thank you.18 Thank you, Mr. Chairman.19
Okay. Are20 there any other questions for these21 witnesses?22 (No response.)23
I'd like to24 ask Episcopal and Northeastern25 55 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Occupational Medicine and Aquahab.2
Good8 morning. Thank you for your appearance,9 your attendance. As you heard in the10 last panel, I would like you to kind of11 give a little bit of background about the12 company, how long you've been in13 business, how long you've had a14 relationship or did have a relationship15 with the City, what interaction with16 CompServices or the City have you had or17 didn't have as a result of how you were18 terminated, just what the circumstances19 surrounding all this. Also, where your20 locations are and the number of people21 you employ would be helpful.22 So whoever would like to start.23 Please identify yourself -- and these are24 old systems, so you're going to have to25 56 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 speak directly into the --2
Good morning,3 Mr. Chairman and Councilmembers present.4 Thank you very much for the opportunity5 to give our presentation today.6
Industrial Health13 Services at Episcopal Hospital. And we14 also own R&B Medical Management, which15 was located at the Northeastern -- known16 as the Northeastern Industrial Health17 Center before we closed that facility and18 amalgamated it into the present location19 at Episcopal Hospital.20
We have been23 involved in the delivery of healthcare24 for work-related injuries, and we have25 57 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 been involved with the City of2 Philadelphia since the inception of its3 managed care workers program, which4 started in 1993. As a matter of fact, we5 bid -- we replied to the RFP that the6 City of Philadelphia sent out at that7 time, and, of course, we did lose out,8 unfortunately, to bigger companies, but9 we were invited to join to be a panel10 provider. 24 We have, I believe, provided25 58 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 very good healthcare to the injured2 members or the employees of the City of3 Philadelphia. We have -- as I said4 previously, we had two locations. 11 Now, prior to closing that12 location, we contacted both the City of13 Philadelphia and CSI to make sure that14 that was not in any way going to affect15 our relationship with the workers'16 compensation program of the City of17 Philadelphia. 23 The main reason for that24 closure that we did was the fact that, as25 59 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 you probably all remember, is that2 Northeastern Hospital closed as an active3 hospital and only maintained an4 outpatient type of presence, and the5 biggest loss there was the loss of the6 emergency room, which took care of the7 work injuries in our assigned area during8 the off hours. We no longer could9 provide that, and the injured workers of10 the City of Philadelphia would get11 treated in far-away emergency rooms to be12 followed by us. Trying to get like a13 quick x-ray report or be able to look at14 the x-ray images from the -- through the15 computer system was no longer available16 to us. 20 There was no continuance of21 care in that regard, and we thought that22 that, plus the fact that the physical23 plant that we were located at was not24 improved despite my plea to improve25 60 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 them -- the elevator was breaking down2 about a couple of times a month and, of3 course, the injured employees can't walk4 very well sometimes, and I was very5 afraid that they were already injured and6 even get more injuries should they fall7 going up and down the steps. 21 We followed what was asked of us,22 including attendance in the monthly23 Medical Director's Meeting, submission of24 reports and even reports that we already25 61 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 5
CSI. CSI is the8 institution that needed medical reports.9 So we sent them to CSI.10
Actually, I was17 not notified. It was my partner,18 Dr. Bonner, who received a phone call19 from somebody at CSI and apparently, to20 my understanding, somebody that neither21 of us who met before nor have talked to22 before.23
Were there24 reasons given for your termination?25 62 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
There was no2 reason given for our removal from the3 network providers.4
I'm Dr. Bill7 Bonner, and I was at the Episcopal site8 when the call came in from an individual9 who I hadn't met before. You must10 understand that we've been involved in11 this program for 17 years' time and we12 saw CSI come from a five-person company13 into a big inner city company that it is14 today, and we knew most of the important15 people in that office like over the16 years. And I received a call from a17 person who had just been hired on to say18 that in the next one month's time that19 all the patients --20
I'm sorry. So23 then I received a call that in the next24 one month's time, all of the City25 63 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 patients would be transferred out of the2 office, with no explanation, no reason.3 I asked, Why? What happened?4 And she said, Well, I don't5 know. This is what has -- like I was6 called to tell you that this is what is7 going to occur.8
So there9 had been no prior correspondence or calls10 relative to dissatisfaction, no11 complaints?12
Been no13 notifications about complaints, been no14 warnings, been no probationary periods,15 been no reprimands, been no -- Gabe16 Rosales had attended the Medical17 Director's Conference two days before he18 was -- or before the call came in to our19 offices. He had met with the Risk20 Management team. He had met with all the21 medical directors up there. He spoke to22 the Medical Director for the City of23 Philadelphia, and nothing was said. He24 walked out the door, came back, he gave25 64 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 me the report, conference went well, here2 are some things that I would like to do,3 and two days afterwards, I received this4 call, shocked.5
And, again,9 you said you've had a relationship with10 the City for 17 years?11
In April, I signed15 a new contract to provide continued care16 to the City workers. I think that's17 attached to our information that we sent.18 And we received no notification by19 written mail. We received only that20 call.21 I did then, after I received22 the call, I was able to reach Lee Herzer23 from CSI. He was kind enough to return24 the call, was kind enough to arrange a25 65 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 date and time for myself to come down to2 meet himself, and he arranged for me to3 come down to meet Mr. Barry Scott.4 Dr. Rosales and I came down,5 and we did meet with Lee Herzer and Barry6 Scott, and were basically informed that7 it was a fait accompli, that the8 decisions had been made without any real9 explanation on why.10
So there11 were no specifics that were given to you12 as to dissatisfaction or price or13 over-utilization?14
Well, they had15 talked about a number that they -- as we16 rolled out this workers' comp program,17 systems evolved, and probably about ten18 years ago, we began to check to see like19 the number of new patients that come into20 a particular office and compare that to21 the numbers of returns, and to have that22 kind of as a compass as to are doctors23 bringing patients back too often. And as24 we discussed with the medical directors,25 66 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 we informed them that that idea is okay,2 but you have to keep in mind that there3 are a number of other things that affect4 that relationship as to the new patients5 to the number of returns. If I have a6 large number of new patients, well,7 that's going to make that ratio look8 small, and on the other hand, if I'm an9 old department and I am seeing a lot of10 patients that I've seen for 10 or 1511 years' time, as Dr. Rosales and I have --12 the other day before this contract was13 taken off of us, I saw a patient in the14 office, a Chief Inspector from the Police15 Department, who I've known for 15 years'16 time. He comes in, still on the City17 panel, still being seen. And I have tons18 of patients that I've been caring for for19 decades now that continue to come back.20 Dr. Rosales is a certified21 trauma surgeon, and the case managers at22 CompServices, Inc., they tend to send him23 the, quote, problem cases, the cases who24 are out for quite some time and they're25 67 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 trying to get a resolution, they want2 somebody to pick up the case and try to3 bring some sort of resolution to the4 case. So he and I receive these5 transfers in.6 So if you have a large number7 of old patients that are coming in,8 you're getting a large number of9 transfers in that aren't going back in a10 couple days' time and your numbers are11 small, you're seeing a small number of12 new patients, well, of course then your13 numbers are skewed somewhat. And these14 issues had been all discussed, and CSI15 and the Risk Management team all16 understood that. And we've worked with17 these numbers for the past ten years'18 time and there's never been a major19 concern, just as a barometer as to you're20 a little off, let's try to work things21 out, but never a major concern.22
Thank25 68 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 you, Mr. Chairman.2 Doctor, if I could just ask,3 and I know you said this, just first4 clear for the record. In taking you off5 the panel, you've never received anything6 in writing?7
As far as9 the notification or the reason, correct?10
During12 your years, I think you said something13 about sending in progress reports or some14 reports?15
Okay.18 Have you over the years gotten things19 back from the City either commenting or20 giving instructions, or from21 CompServices, in writing either saying22 you need to do something else or --23
-- you're25 69 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 doing well or anything like that?2
You never4 get anything in writing back from any of5 entity?6
We did not. And7 we meet once per month, and there's never8 been any sort of reprimand where we need9 to pull you guys aside and say, Hey,10 guys, you stepped out of line here, you11 need to fix this or else.12
And they13 don't do written evaluations, if you14 will, of any kind, positive or negative,15 right?16
Okay.18 All right. Thank you.19 Thank you, Mr. Chairman.20
Sir, could21 you please identify yourself for the22 record and again proceed with your23 testimony within those guidelines.24
My name is Tate25 70 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Rice. I'm the Vice-President of Clinical2 Operations at Aquahab Physical Therapy.3 Our location is at 3600 Grant Avenue in4 the Northeast, and we have approximately5 15 employees that work there full time6 and a handful of part-time people as7 well.8 The City contract for us9 represents about 30 percent of our10 business. So we do between 200, 25011 visits a week. We'll probably get three12 or four evals a week from the City, or13 had been. We've been contracted with14 Premier Comp Services since January 2009.15 We've been contacted by Selena Aron at16 CompServices in the fall of 2008 to let17 us know we were going to be on the panel18 starting in 2009. And over the time, the19 caseload built pretty well and was, for a20 business, very good for us.21
The company itself24 is about 15 years old.25 71 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Did you2 have any contact with the City prior to3 the CompServices' notification that you'd4 be on the panel?5
No. From what I6 understand -- I have been with the7 company about four and a half years now.8 My predecessor had had some contact with9 CompServices, but nothing that ever10 produced anything. So I sort of got a11 call somewhat out of the blue in the fall12 of 2008 letting me know that we were13 going to be on the panel. And then14 starting at the beginning of October, I15 got a call from Sharon Kress at Premier16 Comp Solutions letting us know that the17 City had decided to no longer use the18 panel that Premier Comp had created and19 they were going with their own panel, and20 since that time, we haven't seen another21 new referral since then.22
Do you know23 how many companies were with Premier24 Comp, how many was under their umbrella?25 72 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Four3 companies were under -- and all of them4 were terminated?5
Well, La Fortaleza11 is still on the --12 COUNCILMAN KENNEY:13 La Fortaleza was part of it?14
So the four18 that were affiliated with Premier were19 removed?20
And that22 would be Progress, your company, and23 what's the other one?24
Bustleton,25 73 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Outreach.2
I realize3 there's only four companies we're talking4 about here, but geographically there5 seems to be a bit of a thread. All of6 them are in the Northeast part of the7 City. So I don't know whether that is8 just happenstance or there's an issue9 there that's related to where the10 companies are located.11 How many --12
Well, what I can13 tell you is that of the 30 people that we14 saw week in, week out, I would say15 probably 95 percent of them lived in the16 Northeast.17
Well, the people20 that we had been seeing we're allowed to21 continue to see, so...22
We haven't had any25 74 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 new referrals, correct.2
I'm assuming5 NovaCare, since they're around the corner6 from us.7
Just one14 quick question on this for anyone. I15 understand one of the listings is by zip16 codes. Do you have a certain amount of17 zip codes that you cover or you covered18 when you were in there? Is that how that19 works?20
That's correct.21 For the medical piece, it is divided up22 per zip codes. And our area covered, I23 think, what, six zip codes?24
Seven zip codes.25 75 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Well, like our4 center at Episcopal -- so it was centered5 around the zip codes around that6 particular hospital there. At the time7 that this program was devised back in the8 early '90s, as you may recall, the whole9 City workers' comp program was based out10 of the Hahnemann Hospital here and like11 all the patients were seen there. At12 that time, well, they asked us to come13 down to check it over and to give some14 recommendations as to like what should be15 done, and we came up basically on the16 idea that it needs to be broken down and17 sent out to certain areas around the town18 that the injured person could be seen and19 sent back to their jobs.20 Secondly, though, we asked that21 they be placed in impoverished,22 poor-providing hospitals where the poor23 are being cared for and to put these24 departments in hospitals that are25 76 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 providing a fair amount of the poor and2 indigent care. And that's one reason why3 like we opened up at the Episcopal4 office, because it was a big industrial5 area there, but the idea was to bring6 these patients in to these impoverished7 areas to help support these communities,8 because we then refer patients out to the9 outlying Fortaleza; for instance, the10 minority-owned PT department in that11 area. So we'd refer patients out to12 them. I know that Fortaleza is upset13 with our offices being shut down.14 The second issue is is that if15 you look at the geography of it, now with16 our office taken out of it, you have the17 Hahnemann site here in town. They've18 transferred all of our patients up to19 Frankford, and the other site up there is20 Jeanes. Frankford Hospital to Hahnemann21 is 13 miles as the bird flies. No22 industrial health center in this whole23 area.24 So if you're talking about the25 77 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 geography of it, I'm not sure what the PT2 locations are, but as far as the3 healthcare, the medical end of it is,4 they've taken out a site that can provide5 for the 23rd, 24th, 25th of the Police6 Department as opposed to sending all7 those officers up to the Far Northeast.8 It's going to take them during the day up9 to an hour to travel up there.10
Let me just15 correct myself. We did have a total of16 nine zip codes prior to all of this. And17 also, just to follow up on -- Dr. Bonner18 said that this 13 radial miles from19 Frankford to Hahnemann and six radial20 miles from Frankford to Jeanes. So21 that's a big hole in a triangle that has22 no existing occupational health center at23 this time for the City.24
And do you25 78 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 have anything to add in addition to what2 you've already testified to?3
No. I mean, you4 know, it's an impact on the business.5 The only thing I would say is, I know6 that part of the reason I think that the7 zip codes are created and everything was8 obviously to keep business within the9 City limits, and speaking as somebody who10 works for a company with a location in11 the City, it's going to harm us. I mean,12 there's no question about it.13
Okay. Any14 questions for these witnesses?15 (No response.)16
Thank you17 very much for your testimony.18 I'd like to ask Mr. Scott and19 anyone from the City who is available to20 testify basically offering their own21 testimony and commenting on whatever else22 they'd like to comment on.23 (Witnesses approached witness24 table.)25 79 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
My name is Barry2 Scott. I'm Deputy Director of Finance3 for Risk Management. Thank you very4 much, Councilman, President -- sorry;5 Chairman.6
Thank you for the8 opportunity to testify as well.9 It's the mission of Risk10 Management to provide high quality11 healthcare and control the costs of12 claims against the City, and it's also13 the job of Risk Management to limit the14 number of injuries and illnesses that15 City workers experience. Unfortunately,16 in the course of their jobs, City workers17 experience a number of injuries and18 illnesses. We try to reduce that with19 our safety unit and reduce the number of20 incidents that we have, but we do have21 incidents. When we do have them, we try22 to handle them in the most expeditious23 way possible.24 We have contracted with a Third25 80 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Party Administrator, CompServices,2 Incorporated, to provide us with a total3 package of care for medical care as well4 as management of a legal system and5 defense of claims. The Third Party6 Administrator is responsible -- and as we7 mentioned, they're a wholly-owned8 subsidiary of Independence Blue Cross.9 They provide care for over 3,00010 work-related injuries we experience a11 year.12 One of the responsibilities of13 the Third Party Administrator, one of the14 primary responsibilities, is to contract15 with and credential medical providers and16 provide a network medical panel for the17 City's program. Historically that18 medical panel has -- at one time it was19 PGH where all City injuries were handled.20 Since then under this program, we've21 expanded to have a number of hospitals22 and provide a number of facilities that23 could provide injury care to City24 workers. Each year we have more than25 81 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 23,000 doctor visits and more than 29,0002 physical therapy visits under this3 program.4 Providers' continued5 participation in the program is6 contingent upon their appropriate care of7 injured City workers, their adherence to8 City medical protocols, the adherence to9 the American College of Occupational and10 Environmental Medicine Guidelines and11 satisfactory performance in occupational12 medical care and appropriate conduct with13 the City patients and relevant14 performance measures.15 With me today are Dr. Wilma16 Korevaar, the Medical Director for17 Employee Disability from the City's Risk18 Management Division, also Risk Management19 counsel, Hilary Cornell. Also here are20 Lee Herzer, the Vice-President of21 Operations for CompServices,22 Incorporated; Michael Petrone, the23 Program Manager for the City's program;24 and Sue Gramlich, the Assistant Program25 82 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Manager.2 I'm ready to answer any3 questions -- happy to answer any4 questions that the panel may have at this5 time.6
Thank you7 very much for your testimony, for your8 attendance here today.9 Part of the genesis of this10 whole hearing has been a bit of the11 confusion as to when an inquiry is12 made -- and all of our Council offices13 get inquiries -- either how do we become14 part of the City system to provide15 services or why have we -- why was it16 decided to stop sending referrals or17 employee cases to a particular company.18 And I know from my own perspective when I19 or my staff makes those inquiries, I have20 been told that the reason that we hired21 CompServices, Inc. was to remove the City22 from or at least distance the City from23 that decision-making process. But then I24 wind up -- I pursue attempting to get a25 83 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 company that's been in business for 202 years in the City providing physical3 therapy to get onto a panel and was not4 successful and told that they couldn't5 get on because CSI didn't feel that they6 were appropriate. And I accept that. I7 mean, that's what I've been told.8 On the other hand, I have9 companies that have been doing business10 with the City or providing services to11 City employees for 17 years, for 1312 years, for seven years, for two years13 that are eliminated from doing City work14 without any notification. I mean,15 normally you would think that if someone16 is not meeting standard or not living up17 to what they said they were going to live18 up to, that there would be a phone call,19 a meeting, a contact to say, Look, we've20 evaluated this particular quarter, we're21 not happy with your performance and we're22 giving you 30 days to come up to speed or23 by next quarter you could be in jeopardy24 of losing your position. I mean, simply25 84 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 stopping the referrals coming to a2 company with 25 and 30 employees, who are3 making investments in their company based4 on the expectation of continued work with5 the City, especially since no one,6 according to their testimony, has ever7 complained that they've been anything8 other than providing decent service,9 seems to me to be at least not very10 businesslike and somewhat offensive to11 companies who are established in the12 City, employing City residents, employing13 folks and paying taxes, all the sudden14 after a three- or four-week period come15 to the conclusion that they're out,16 without even having a letter sent to them17 or a phone call made to them. And I just18 don't understand how that could happen.19
Well, first, let me20 just say our ideal is not to send any21 business to any of these providers,22 because our ideal is not to have City23 workers getting hurt. And so we are24 always trying to reduce the number of25 85 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 injuries that we have among City workers2 and City workforce and trying to reduce3 the number of people we're sending to4 these providers.5 To the extent that we have6 business that we do send to these7 providers, we are working to make sure8 that they provide care in a good way.9 We've looked at a number of measures of10 their quality of performance and track a11 number of those measures in order to12 evaluate their performance. We also get13 feedback from the departments whose14 injured workers go to those treatment15 sites. And it is that information, both16 performance measures and feedback that we17 get from departments, that help to inform18 us about what our feedback is to19 CompServices about the medical providers20 on the network panels.21
Who does22 the evaluation of the City workers, who23 gets sent, how long they're there, what24 type of therapy they receive and how25 86 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 effective that therapy is? Who makes2 that evaluation?3
Well, it's a4 managed care system. It's a managed care5 system. The primary care doc -- we have6 a number of -- we have six primary7 treatment sites. Those six primary8 treatment sites are where you go to your9 main doctor. You then are also farmed10 off to specialists, as needed, where the11 doctor is not able to handle your12 particular issue. That's where the care13 decisions are primarily made.14 We review those with nurse case15 managers that CompServices has, and16 CompServices also has a medical director.17 The City also has a medical director in18 Dr. Korevaar. Dr. Korevaar provides19 oversight for the medical program and20 resolves issues where there are conflicts21 or concerns about the medical care with22 regard to what a patient is receiving.23
How are24 those conflicts or concerns articulated25 87 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 to the provider of the services if in2 fact they contend at this hearing today3 that they have never had any interaction4 on a negative side with CompServices,5 Inc. or with the City, it just happened6 that one day they realized that they were7 out?8
Could you11 please identify yourself for the record.12
I'm sorry. I'm13 Wilhelmina C. Korevaar, M.D., and I have14 a contract with the City. I work in Risk15 Management as the Medical Director for16 the Employee Disability Program, and I've17 served in that capacity since 1996,18 initially through CompServices and since19 2000 directly.20 One of the reasons why I was21 brought into Risk Management was so that22 injured employees, their representatives23 or the departments could contact me about24 grievances or complaints. I could review25 88 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the records, then contact either the2 medical director or the case manager at3 CompServices so that feedback could be4 given to the provider. And there is a5 grievance process, just to address one of6 the things that exist, in which the7 employee will then be asked to write a8 grievance, the provider to provide a9 written response. That's one aspect of10 the way in which the program is11 monitored. Because it's a managed care12 program, it's important that the injured13 employees have an avenue for grieving.14 If they don't get along with the doctor,15 for example. Because there are limited16 sites, we need a way in which the injured17 employee can get to a site where he or18 she is comfortable.19
When you're20 talking about the six sites, primarily21 you're talking about hospitals?22
But that's25 89 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 a separate layer than the folks who2 testified here earlier, correct?3
So of the5 six sites, if I am an injured police6 officer and I go to -- is Hahnemann one7 of them?8
And I go to10 Hahnemann and I don't like my doc and I11 want to complain about that and get sent12 to another of the other five sites,13 that's a process?14
All right.16 How does that then trickle down to the, I17 guess, on-the-street folks who are18 actually providing the physical therapy19 and rehabilitation?20
The doctors at21 the sites that are hospital based and the22 physical therapy sites are zip code23 allocated, and it's the work site zip24 code. The idea being that you may be25 90 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 able to work in a modified capacity and2 still get to treatment and that treatment3 will be relatively close to where you4 work, and it is up to the treating doctor5 to write a prescription for physical6 therapy.7 Now, there are many work8 injuries that do not require any physical9 therapy and then there are work injuries10 that require some physical therapy. On11 average, there should not be more than12 six to 12 physical therapy visits per13 injury. So it really should not ever be14 the case that three to five new visits a15 week should account for 30 percent of16 business, unless there are too many17 visits. And so one of the other things18 that CompServices does on behalf of the19 City is monitor the number of visits to20 the physical therapy sites and the21 overall cost of physical therapy, and as22 a result of that monitoring,23 periodically, let's say every two to24 three years, the physical therapy sites25 91 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 may be changed because there is a2 perceived problem with over-utilization,3 exceeding guidelines.4
Now, does5 that contract with CompServices, Inc.6 require them to interact, interface,7 communicate with the physical therapy8 providers that in fact, in our managed9 care opinion, you're seeing too many10 folks too many times?11 I don't know what the12 individual situations in these particular13 four companies are, because I haven't had14 a chance to investigate how many people15 they've seen and over what period of16 time, but shouldn't either CompServices17 or the City, as they do with other -- as18 Independence Blue Cross does with other19 providers, say, Hello, this is your case20 manager, we got a little issue we need to21 sit down and talk about, these five folks22 have been here more than 15 or 20 times,23 it's out of line, we need to get that24 back in sync, as opposed to just stop25 92 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 sending them folks?2
CompServices has3 case managers, and those case managers4 interface with the physical therapists as5 well as the physicians who are continuing6 to prescribe the therapy once six weeks7 of therapy is exceeded. And I meet with8 the physicians once a month, and one of9 the things that we go over repeatedly is10 the physical therapy over-utilization.11 Now, the doctors tell me that12 the physical therapists somehow are13 independently continuing to treat the14 patients, and the physical therapists15 tell the case managers that the doctors16 continue to write the prescriptions even17 though they're saying this person has18 plateaued.19 So there is a lot of20 communication. However, your point is21 well taken, clearly the communication22 isn't leading in the proper direction.23
But the24 communication should, I would think, be25 93 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 initially in an effort to resolve the2 issue or to improve the issue. Because3 what happens to me is that when I hear4 the testimony about the lack of5 communication, I have to take them at6 their word. I mean, they're sitting here7 telling me that the only contact they get8 from CompServices is, yes, we received9 your reports, no news is good news,10 everything seems to be fine, you know,11 and all the sudden we're out. And what12 happens is that I look at the current13 panel and I see La Fortaleza, which14 remained on two panels, and I see nine15 NovaCares and then four Mercy Health. I16 still need to understand the business17 process and practice of saying to a18 company that's been working for the City19 or with the City for 17 years or ten20 years or five years, Things are going21 bad, you're not going in the right22 direction, we're getting ready to notify23 you 90 days or 60 days, whatever the24 contract says, you either got to clean up25 94 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 your act or you're not going to be with2 us. I mean, I know that happens with3 medical practices, with other types of4 medical providers, that, Look, we're not5 going to contract with you again if you6 don't get your numbers where they need to7 be, as opposed to saying nothing.8 Now, maybe CompServices or you9 guys are aware of contact with these10 particular companies or others that have11 been removed that would indicate that12 what they're telling me is in fact not13 accurate, but I sense that it was pretty14 much a surprise to them that they were no15 longer getting any referrals.16
With regard to17 the doctors, they've been informed that18 the panels would be changing since July19 at the meetings, and I did have other20 provider sites' physicians come to me at21 the end of the monthly meeting to ask22 about specifics. So --23
These are24 the docs, though.25 95 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
These are the2 doctors.3 With regard to the physical4 therapy sites, we do count on5 CompServices to maintain contact with the6 administrators of those pieces. Mercy7 Work Care has administrators, NovaCare8 has administrators, and Premier Comp9 Solutions has an administrator. And then10 those administrators are the ones11 responsible to communicate with the12 individual provider sites that they13 oversee.14
But based15 on the testimony of the prior16 individuals, that contact didn't happen.17 I mean, where the rub is is that --18 there's two issues: Whether or not they19 overtreated or the doctors20 over-prescribed and whether or not these21 folks were ever notified of any of this.22 I mean, and that's where I still don't23 have any clarity as to who at24 CompServices or Risk Management is25 96 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 responsible for picking up the phone and2 saying, Dr. Bonner or Mr. Mohollen, get3 me your business person or your director,4 let's get in here and talk about this.5 Because it doesn't seem that that6 happened. It just seemed that they ended7 and were replaced by someone else.8
And I can speak to9 some of that. There's some extent in10 which the communication didn't happen as11 it should have, and I did apologize to12 Linda Schmac and I also apologized to13 Dr. Bonner about the communication not14 happening appropriately. However, in the15 case of Episcopal/Northeastern, there16 were a number of contacts with them over17 a period of time which expressed concerns18 about treatment and care that was19 received there, and those contacts were20 made between CompServices primarily.21 We have Dr. Korevaar with us a22 few days a week. She's not with us full23 time. We really count on CompServices to24 be the primary conduit for communication.25 97 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 They do that through --2
Currently it's5 Dr. Dituvich (ph), but they have a new6 medical director, Dr. Dragoon, who is7 coming on board now.8
Are either9 of those docs the ones that are examining10 this information and making11 determinations?12
Yes, they are, and13 they also have the nurse case managers14 who are examining that information.15 There are three real lines of authority16 there. The nurse case manager is the17 primary one who deals with you, the18 patient, and your provider about your19 care, and then the nurse case managers20 then report to Ms. Gramlich, the21 Associate Program Manager for22 CompServices. Then the Medical23 Director -- they also report to the24 Medical Director of CompServices. Then25 98 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 CompServices also has a Director of2 Provider Relations. Her name is Carrie3 Blouse, and she's the one who oversees4 the relationship between CompServices and5 all of their providers.6 The providers provide care not7 only to City of Philadelphia, they8 provide to their other clients as well9 these medical panels. And so the10 communication that happens between the11 case manager and the medical director at12 CompServices and provider relations at13 CompServices is information that14 CompServices reports on to us. They keep15 us informed somewhat about that, but16 they're primarily concerned with17 communicating with the provider about how18 their provider is performing along a19 number of metrics. Those communications20 went on in the case of Episcopal and21 Northeastern.22 With regard to physical therapy23 providers, we really have been -- we have24 not done what we should have in terms of25 99 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 communicating with physical therapy2 providers, and we've -- we're in the3 process of changing that so that we're4 communicating more with the physical5 therapy providers now.6
Let me go a7 little bit backward, because my8 understanding from previous testimony --9 and maybe it's accurate or inaccurate --10 that NovaCare -- and it's a fine company11 in the City and I happen to know the12 folks that are involved there and I have13 nothing but respect for their company,14 but I understand that at one point in15 time, they were removed from the16 provision of services. What were the17 circumstances of their removal and what18 were the circumstances of their19 redemption?20
They weren't21 removed completely, but the number of22 sites that they had was reduced, and it23 was because of over-utilization.24
The number25 100 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 of sites they had were reduced?2
No. This is the6 current panel. Prior to this panel,7 NovaCare had fewer sites. They had like8 four or five sites on, and then we had9 the Premier Comp sites, who you heard10 from this morning. So those sites were11 on, and those were sites primarily in the12 Northeast that were selected, because we13 wanted to make some changes to try to14 tinker with what was available in that15 section of the City.16
So17 basically the additional NovaCare sites18 replaced the Premier Comp sites?19
Going back,21 though, to when they were removed, they22 at one point had more than nine sites.23 The physical therapy utilization got very24 high and we noticed that it was coming25 101 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 out of the NovaCare sites, and that2 prompted us to reconfigure the physical3 therapy sites and to bring in the four4 sites from Premier Comp Solutions. We5 were hoping that that would bring the6 physical therapy utilization down, but it7 didn't. It actually went up even more.8
Let me ask9 you a question. La Fortaleza was part of10 the Premier group, right?11
No. They've13 never been -- they've always been an14 independent group, and their utilization15 has remained pretty steady. They haven't16 taken the cases and started to just turn17 them, and that's why they've remained on18 the City panels through these other19 changes.20
See, I21 think part of the issue that brings us22 here today is that -- and I do respect23 the Administration's striving for this24 transparency, but the issue here seems to25 102 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 be less transparent, because there's2 decisions that are being made that affect3 companies that employ folks without even4 a period of time, like within a year,5 that you can say, by the way, we're not6 sending you any more folks. How do you7 create a business plan and maintain your8 business if at any given time you can9 have the rug removed from under your feet10 and without, according to their11 testimony, without any notification?12
But no business13 in healthcare has any business counting14 on a single employer to maintain their15 business. That isn't a wise business16 plan at all.17
But that's22 kind of after the horse has gone to the23 barn, that we recognize there's been no24 notification, we think that's wrong,25 103 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 we're sorry, but in the meantime, we've2 reinstituted four more sites to a company3 that had five sites already. I mean, to4 me -- with a company that had been5 reduced once before.6 So it seems that -- I mean,7 it's not like they didn't have their own8 problems when they lost their four sites9 previously, and now not only do they have10 five, they have the additional four.11
But there's no12 guarantee when you're on any panel, as a13 physician or physical therapy site, that14 you will remain on that panel. A panel15 is an employer designation. That's16 really all it is, and panels change all17 the time.18
But it's19 not just a private company employer20 designation. This is a public company21 with public requirements, that at least22 folks need to know. I mean, this is a23 legislative body that votes on budget24 issues that are related to Risk25 104 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Management, the Finance Department,2 things that we have -- we're the Board of3 Directors of this company and I have4 elements of the company making decisions5 that really don't feel any need to inform6 anybody about and just go ahead and do7 it.8
No. I'm11 speaking about my role on the Board of12 Directors of the City of Philadelphia,13 the 17 members of City Council, who have14 oversight over this government, along15 with the Mayor, who is the Chief16 Executive Officer. I don't understand17 how one segment of the government18 independently can make decisions based on19 companies that are existing in the City20 just shifting business around from one21 folk to another without any notice. I22 mean, how do you not notify the people23 who are losing the work or the folks who24 are responsible for the oversight of the25 105 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 spending of the money? It just seems2 that there's this -- and I'll tell you3 personally why I get upset about it, is4 when I make a call to make an inquiry5 about a company that wants to6 legitimately compete to get in, I'm told,7 You know what, the City is not involved8 in that. We hired that Third Party9 Administrator to get away from that10 problem. Or if I call to complain or11 make an inquiry as to why a company that12 comes to me as an elected official and13 says, We got knocked off without being14 told, I call to find out why that15 happened and I get an answer, You know16 what, we hired that Third Party17 Administrator so we didn't have to deal18 with this. So that was their decision to19 make. And then privately I am told --20 and I'm not going to be specific about21 the case -- that the Third Party22 Administrator says, You know, we don't23 always agree when they want to get rid of24 somebody. We kind of argue that they25 106 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 they're okay and we should keep them, but2 the City decides that they want them out.3
I mean,6 it's very confusing, and when it all gets7 confusing like this, you start to wonder8 how people wind up getting removed and9 then how people wind up getting replaced10 and what's the motivation.11
The motivation12 always is quality of care and cost for13 the City. That's the motivation. What14 we are looking at is the quality of care15 that's received by our injured workers16 and what the cost of that care is. We17 are looking to balance those things in18 cases of thousands of injuries that come19 through the centers annually, and we are20 looking at a number of -- as I said, CSI21 looks at primarily the metrics. We look22 at the relationship with the patients,23 with the individual employees, in order24 to make sure that City employees are25 107 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 respected in their care.2
The decision is8 usually made jointly. CSI has -- CSI has9 the responsibility to manage that panel10 for the City of Philadelphia. The City11 has the ability to override or overturn12 what CSI has said, because we can have13 some input. We need to have some input.14 But we have had cases where -- and it's15 not something that we're happy about, but16 we've had providers -- and none of them17 here today -- who have abused City18 employees, they have made sexual19 advances. There have been a number of20 things --21
They22 shouldn't be eliminated; they should be23 indicted and arrested. But that's a24 whole different...25 108 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
I'm just saying in2 terms of managing the care and in terms3 of the kinds of controls that we want to4 have in terms of our ability to be5 flexible, this program requires a lot of6 ability to be flexible, and that's why we7 use CSI to contract -- to provide that8 contract.9 Also, just to sort of follow up10 on Councilman Goode's question from11 earlier today, there is a minority -- the12 Premier Comp Solutions was named in CSI's13 contract at about $96,000, and they14 received over half a million dollars in15 the last fiscal year. So there was a16 commitment. That commitment was met and17 exceeded.18 COUNCILMAN KENNEY:19 Councilwoman Krajewski, do you have20 questions?21
Thank22 you.23 I don't know, but do we have a24 list of the new providers?25 109 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
How5 about the names of the ones that you6 removed? Do we have a list of them?7
Could11 I have a list or the Chair have a list of12 the ones that we removed?13
I'm sorry.18 In addition to the list of those removed,19 what the reason was for the removal.20
Right.21 I mean, do you have any22 documentation to support that using these23 new providers will result in additional24 savings to the City?25 110 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Well,3 we'll send that over with it, too. I4 appreciate all that information being5 sent over to the Chairman.6 That's the main questions I7 wanted to ask.8
Just so the9 record is clear, based on the10 recommendations from CompServices and11 their metrics and their analysis, who12 makes the decision to remove a provider?13
It's a decision14 that's made jointly between CompServices15 and Risk Management.16
So17 CompServices is making the decision or18 they're providing you with the19 information so you can make the decision?20
They would need our25 111 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 approval to remove someone from the2 panel.3
Based on --7 there's no legislative responsibility or8 legislative authority deemed to9 CompServices to remove anyone. They are10 a contractor, as I understand it, with11 the City to provide resources and12 information and analysis, but the City13 makes the final decision on the removal.14
Correct,17 but they have no statutory authority to18 remove anyone.19
Thank23 you, Mr. Chairman.24 If I can just add to -- and I'm25 112 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 not sure if exactly she asked for this,2 too. On the list that you're sending to3 the Chairman, Mr. Scott, I know she asked4 about the physical therapy folks, which I5 know we're concentrating on here today,6 but how about the same information on the7 doctors --8
-- and10 their zip code? I don't know if that was11 made clear. We would like that too, if12 possible. And whatever those doctors'13 specialties are, like what they14 specialize in.15
And just17 generally -- and I know Councilman Kenney18 has been asking this, but I guess what19 I'm really -- if you heard the questions20 I've asked of the previous witnesses, I21 guess I don't understand why at least22 something wasn't sent in writing to these23 people kind of explaining what the24 problem was, either beforehand, a warning25 113 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 letter, if you will, or, at the very2 least, afterwards. Because just having3 all this verbal thing -- and like4 Councilman Kenney said, I don't have any5 reason to doubt these people, but it6 would seem like it would cover you guys7 better if you had something in writing8 and saying this is why Premier Comp9 Solutions was taken off the panel,10 something to that effect.11
Yes, Councilman.12 My name is Lee Herzer, Vice-President of13 Operation for CompServices.14 I think your point is very well15 taken. I think that's something that we16 will implement into the future. However,17 I think it's important to point out that18 the contracts that these providers have19 and any providers have with CompServices20 don't guarantee nor even imply their21 participation in any panels whatsoever.22 It's a contract to provide care with23 CompServices. We have other clients24 besides the City, including SEPTA, the25 114 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 Commonwealth employees. We handle the2 claims for the 90,000 state workers and3 many other businesses throughout the4 state.5
I6 understand there's no guarantee, but I7 guess -- again, I think Councilman used8 the term just fair business practices. I9 mean, it just seems so, for lack of a10 better term, loosey-goosey the way this11 is all done, you know. They don't find12 out, then somebody gives them a call, and13 somebody is not sure if it's them or the14 City. You know, I mean, it's kind of15 very non-professional. I don't mean to16 preach here, but good grief.17
As Dr. Korevaar18 indicated, I think, earlier, the meetings19 that are held between our medical20 director, the City medical director and21 the medical directors of the six prior22 sites, I believe that Dr. Korevaar's23 opinion was that some of the providers24 were given adequate verbal notice that25 115 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the City had issues with some of the2 things that were happening at the3 different sites.4
It seems5 to be -- I'm sorry. It seemed to be6 disputed. I think the answer to my7 questions and the other Councilmembers8 were that they were not told anything.9 Now, I don't know, but that's where I get10 back to sort of the writing idea. I11 mean, after a while -- I like the12 personal contact too, but after a while,13 it seems like almost a -- a regular14 employee, when he or she screws up, gets15 a warning letter so that they can't later16 say, I didn't know I had a problem, you17 know. It just seems like the best way to18 cover everybody in this, and then there's19 not a he said/she said thing. Well,20 here's a letter. But from what I hear21 from Premier Comp, that the only thing in22 writing was the e-mails that they sent to23 the City or to CompServices or both,24 whatever.25 116 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
That's correct.2 Our Director of Provider Relations made3 the phone call and that's how notice was4 given.5
But I6 think it was after the inquiry was made,7 correct, like why aren't we getting --8
No, I don't9 believe that to be true at all. I10 believe that a call was made to Premier11 Comp within two days from when the12 decision was made and prior to the13 delivery of the panels.14
Well,15 obviously you can't -- and I'm not16 doubting you, like I can't doubt them,17 but, you know, again, just something in18 writing.19 And are there exactly written20 guidelines, again, maybe that we could21 see too as far as like Dr. Korevaar22 talked about the repeat visits, that kind23 of thing? Is there some kind of basic24 guidelines that you're supposed to meet?25 117 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Right. Our2 medical providers and our nurse case3 managers are supposed to follow the ACOEM4 guidelines, as Dr. Korevaar mentioned,5 that provide standards of care for6 various types of injuries based on the7 diagnosis code, what protocols should the8 doctors be following to treat injured9 workers with a specific injury.10
Yeah.15 Could we get a copy of that? Because16 that way I think we're clear on some of17 it.18
I'm just19 curious as to once an injured worker20 receives a prescription from one of the21 docs from the six sites and takes that to22 the zip-coded-required place they go, do23 they need a prescription every time they24 go?25 118 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
So why4 aren't the docs who are writing the5 prescriptions as much at fault as the6 folks who are carrying out the7 prescripted request of a medical person?8 I mean, it seems to me that if I have six9 sites and six docs or six practices that10 deal with this and every month that11 employee gets a new script to go back to12 Dr. Bonner or to Bustleton, why is the13 provider of the therapy at fault and the14 doc doesn't have any ramifications for15 writing the script up every month?16
The doctors are17 called to task on this monthly at the18 Medical Director's Meeting.19
The meetings are22 memorialized in writing. I do minutes23 and an agenda. And every month this is24 emphasized and the doctors are told that25 119 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 we expect you to adhere to the2 guidelines.3
So the docs4 that wrote the scripts that created the5 over-utilization of these particular6 companies, are they all still part of7 this network? Has any of the docs been8 removed who have written multiple scripts9 that put these folks in the position that10 they're in to be removed from the system?11
Not to13 interrupt you, but it would seem to me14 that if I'm a physical therapist or15 running a physical therapy company and I16 have a doc who is, of course, somewhat17 above me in ability and in education and18 in experience, that if I get that script,19 I should carry out that request. I20 shouldn't be penalized for a doc -- or at21 least be unilaterally penalized for a doc22 who keeps writing scripts monthly for23 folks who are now putting these people24 out of the network.25 120 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Well, actually,2 there are physical therapy guidelines3 that state that when a person reaches a4 plateau, it is your job as the therapist5 to communicate that back to the doctor,6 and part of what we've asked of all the7 physical therapy provider sites is that8 they oversee the therapists so that that9 does occur, so that they remain within10 the physical therapy guidelines for11 numbers of visits.12
But they13 can't get reimbursed without the14 prescription. If, for example, I have15 hurt my back and I go to my --16
-- site and19 I get my prescription and I go for the20 standard set of therapy and I plateau,21 how do I get continued therapy without a22 prescription?23
You don't need24 continued therapy when you plateau. In25 121 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 fact, there's good evidence --2
-- that if you5 keep going, you become dependent and you6 get worse.7
I'm not8 arguing that. I'm not arguing the person9 shouldn't plateau. What I'm saying is is10 that how does the physical therapist11 continue providing service to a plateaued12 patient without a prescription from the13 doc at one of the six sites?14
Correct.21 So if they don't have a prescription from22 the doc at one of the six sites, how does23 the therapist get paid for continuing to24 provide service that the doc hasn't25 122 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 authorized? You're telling me the2 patient needs a prescription every month.3
But we also -- one4 of the other things that we find is that5 these providers have a higher cost per6 claim than --7
That's8 another issue. That's a separate issue.9 I'm just talking about the frequency.10 The frequency of physical therapy being11 given to a patient is based initially on12 a prescription from a doctor that needs13 to be prescribed again every month --14
So now when19 the person plateaus, why is the doc still20 issuing a prescription for continued21 physical therapy?22
Okay. The25 123 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 doc should not be. So why isn't the doc2 removed, just like these other companies3 have been removed, for providing more4 services than is authorized?5
There are some6 doctors who are on our panel by labor7 agreement, and those doctors I can't8 remove from the panel without --9
But think14 of kind of the silliness of it, is that I15 have a physical therapy company that16 loses its relationship with the City17 somewhat based on prescription18 requirements being issued by doctors at19 six approved sites that can't be removed20 for things that they do.21
We have physical22 therapy sites, including La Fortaleza,23 who will not continue to treat when24 someone has plateaued, who will pick up25 124 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the phone and talk to the doctor, even2 the doctors that we cannot remove. And3 so --4
So you're5 telling me that a physical therapist can6 call up a doctor and tell he or she as a7 doctor that you're wrong, stop writing8 these prescriptions?9
It has happened13 to me, and I respect the therapist.14 That's why I send my patient to the15 therapist to start with. The therapist16 is the one who knows when a plateau has17 been reached. I count on the therapist18 that I send my patients to to do just19 that.20
How many21 docs are beyond reach of the six sites22 contractually, they could write a script23 a day and you still can't get rid of24 them?25 125 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
They're not in that2 six, that group of six. There are3 another four docs in this other group.4
Initially8 the testimony was there were six sites9 and six practices that dealt with this.10 Now where are the other four from?11
The other four are12 primarily -- there's three in the13 Northeast and one in South Philadelphia.14
They have to sign a21 contract with CompServices.22 COUNCILMAN KENNEY:23 Councilwoman, do you have any other24 questions, because I do think -- I25 126 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 appreciate your being here and your2 patience. It is an extremely complex and3 somewhat less than transparent -- I don't4 even like the word "transparent," but5 since it's been used so much, somewhat6 less transparent than I would like, and I7 do feel that there are folks who are8 legitimate businesses in the City who9 have had relationships with this process10 for years that are now gone, and there's11 still some other stuff there that just12 seems like it needs more explanation or13 at least more light.14
Some of the -- and15 I apologize for some of the lack of16 transparency. It has to deal with the17 medical issues that play and the patient18 care issues.19
We're not20 getting into HIPAA. That's not the21 issue. I don't need names and Social22 Security numbers. I'm just talking in23 generalities how folks move through this24 process. But I still believe that it is25 127 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 inherently unfair to eliminate a company2 that is providing services that's being3 prescribed by a physician. And, you4 know, Doctor, you've made your comment5 that any physical therapist would call up6 and challenge that physician. I don't7 know whether -- I've never seen a nurse8 challenge a physician or a physical9 therapist challenge a physician, because10 physicians have their own view of11 themselves and their abilities, but I12 guess --13
And just to say,16 that one of the things that we're also17 looking at is the fact that we have a18 provider who can provide the care at a19 lower cost to the City. And so if I have20 Provider A and Provider B, and Provider A21 can provide me the same services that22 Provider B can provide at a cheaper cost23 to the City, that's one of the things24 that we're looking at as well.25 128 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Rates are also11 negotiated between CompServices and the12 providers.13
But it's14 still within the guidelines of what the15 City wants to spend. So, I mean, if16 there is a guideline of what the City is17 looking for themselves to spend on18 physical therapy, you really can't go too19 far outside that guideline, and when you20 contract or put a company on a panel,21 going in you know what their numbers are.22 Their numbers change during the course of23 the year?24
Well, why2 do you let that happen? Reimburse them3 for what you agreed to reimburse them4 for. I mean, if I have a contract and I5 say I'm going to provide X, Y and Z for a6 certain price and six months later I7 double the price, you're not paying me.8
No. Our contracts9 are based on and workers' comp is based10 on a state fee schedule. So our11 contracts are based on a percentage below12 the state fee schedule or a daily rate,13 so --14
Is the15 state fee schedule higher than what the16 City's fee schedule is?17
The state fee18 schedule is higher because we're19 contracting at a percentage below the20 state fee schedule.21
How do we22 get away with charging less than what the23 state fee schedule is?24
It's contracted.25 130 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
But the2 state fee schedule, I assume, is in some3 state code somewhere.4
But the Workers'6 Comp Act allows companies like7 CompServices to contract with providers8 at something less than the state fee9 schedule.10
Thank13 you, Mr. Chairman.14 I just want to spin off in just15 a slight different direction, if I could.16 Just quickly, because I know it's been a17 long hearing, but I'm looking at more18 towards the treatment or the procedure19 for the employee if he or she gets hurt.20 Can you just briefly take me through the21 process. Somebody gets hurt, where do22 they start, you know, that kind of thing,23 Mr. Scott.24
Assuming that it's25 131 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 not an emergency injury where someone's2 life is at risk, they would go to one of3 our treatment sites based on the zip code4 of their work location. They would go to5 those sites. They would see the primary6 care doctor. The primary care doctor7 would diagnose them, would prescribe8 whatever needed to be prescribed, maybe9 medication, maybe they needed some10 diagnostic work, some diagnostic imaging,11 maybe they needed some durable medical12 equipment. The primary care doctor would13 prescribe that. If they needed to see a14 specialist, the doctor would identify a15 specialist that they would need to see,16 and then that person would be referred17 through the nurse case manager at18 CompServices for an appointment with19 those providers, any specialist providers20 or follow-up care.21
Now, the22 doctor prescribes a certain treatment.23 Is that always what happens or does24 somebody else intervene to say, We think25 132 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 this is appropriate or not, if you know2 where I'm going with this?3
The nurse case4 manager, the medical director and -- the5 medical director of the CompServices and6 the medical director for Risk Management7 may all intervene in some way if there's8 a concern about the care. The system9 that we're providing here is a system for10 injury care, and so it is really11 important that the providers in this12 system focus on the work-related13 injuries. There's another system for14 handling my degenerative conditions, and15 that's a system that we don't run.16 We are -- so we're really trying to17 always tease out those conditions which18 may be a condition that a person comes to19 us with from the work-related injury. So20 we're looking at providers who are able21 to make that distinction and that22 determination and provide care for the23 work-related injury exclusively.24 There's a number of things that25 133 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 may happen. A doctor may not accept2 workers' compensation insurance, so they3 will not take a case that is referred by4 our doctor because they don't take5 workers' comp, and there are a number of6 physicians who practice in that way.7 They may be outside of our jurisdiction.8 Workers' compensation law works by state,9 and so those doctors in the State of10 Pennsylvania work under a different set11 of rules than those doctors in New Jersey12 and Delaware and Maryland and New York.13 So the rules that the doctor may work14 under also play a role in it.15 So those things may be -- it's16 a fairly complex thing. In most cases --17
In most cases, it20 rolls fairly straightforwardly, because21 the doctors are in our system, they know22 the specialists. We have a number of23 specialists who are on the panel in our24 system and so we use those providers for25 134 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 the specialized care.2
I mean --3 and you know there's one case that you4 and I talked about, but just generally, I5 know you hear sometimes that people say6 or City employees say, Well, I got this7 recommendation from the doctor I saw, and8 somebody else is saying, whether it's9 CompServices or Dr. Korevaar or somebody,10 is saying, you know, No, that's not the11 way to go. So I think that's the sort of12 frustration sometimes.13
We, over the14 years, have had problems sometimes15 finding specialists. You may recall a16 number of years ago many specialists left17 Philadelphia County because of the18 malpractice awards, and we had to really19 work hard to fill the gaps on our panels.20 I get questions from21 CompServices frequently about whether22 somebody can go off panel to somebody who23 does a very specialized kind of surgery,24 for example, and I try very hard to25 135 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 identify a person within Philadelphia to2 whom this patient can be referred if we3 don't have such a person on the panel.4 We do try to stay within Pennsylvania,5 and the reason for that is because if you6 leave Pennsylvania, then if the provider7 does not hold a Pennsylvania license,8 they may balance-bill for the total9 charges, and we do not want any of our10 injured employees to be balance-billed,11 because under Pennsylvania law, they12 should not be. So we do try very hard to13 stay within Philadelphia. It happens14 pretty frequently that we need to look15 around to find a specialized doctor, and16 we do our best. It's not always as17 simple as it may seem.18
No; I19 understand. But at some point, the20 person, the employee, needs some21 treatment and they want to make sure that22 they're getting, I guess, what they're23 supposed to and what the doctor that24 examined them is saying they should get.25 136 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 I guess that's the concern. And I2 understand cost and all. We're well3 aware of that. So I get you, but I think4 in some cases we've heard it can be kind5 of frustrating. It seems to take a6 little bit of a long time, and it has to7 go touch a lot of hands sometimes.8
Well, it9 actually comes usually pretty directly10 electronically to me. Even if I'm not11 down here, I'm on my e-mail more than I12 should be, and I take it with me on13 vacation. So we do try very hard. Barry14 sends me requests as soon as he gets15 them. We try very hard not to have a16 time lag. Sometimes we can't control the17 time lag. Sometimes doctors aren't18 willing to see somebody for a couple19 weeks, and there's nothing that we can do20 about that.21
Just22 lastly, Doctor, just so I'm clear, you're23 not a City employee; you're a contractor24 with Risk Management?25 137 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Just one other4 thing. One other thing that happens is,5 we also will be mainly trying to do --6 frequently trying to do conservative7 treatments. Our first option is not8 always going to be a surgical option, and9 so we will treat someone conservatively10 perhaps for a time, and then the11 conservative treatment is not successful12 and we need to then go to a surgical13 option. And so that does delay the care,14 and someone sometimes is prolonged in a15 medical condition because of that.16
But when17 you say "we," I mean, if a doctor that18 examined the person is saying maybe the19 surgery is needed, who is the "we" that20 might decide not to, or to go the21 conservative way, as to use your words?22
If one of our23 treating doctors says that this is a24 recommendation, then we move forward with25 138 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 that, and it may require going off panel2 in order to do that. Really the delay3 happens because that specialist may not4 have an opening, or if a recommendation5 is made to leave Pennsylvania, then that6 may result in a couple days' delay while7 we try to find a specialist in8 Pennsylvania who can do the work, because9 we don't want the work to leave10 Pennsylvania, if possible.11
Okay.12 All right. Thank you.13 Thank you, Mr. Chair.14
Just15 quickly, CompServices indicated that16 although they won't send City referrals17 to these folks who have been removed from18 the panel, but there are other19 contractual situations they have with20 SEPTA, state employees, whatever. Do21 these folks still continue to get22 referrals from those other than the City?23
Yes. Premier Comp24 Solutions is still on a number of our25 139 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 panels.2 And, Linda, you would probably3 know more than I would as to how many4 they're on.5 And I believe some of the6 providers that were here today are also7 on SEPTA panels.8
So what9 would be the difference between an10 injured SEPTA employee and an injured11 City employee that would allow12 CompServices to make a referral that13 precludes them from referring the City14 employee? Is there a different fee15 schedule? Is there a different set of16 standards? I mean, if he can send them17 one public employee, he can't send them18 another doesn't seem that consistent.19 Not that I want you to stop sending them20 the other employees. I just don't know21 what happened with the City employee that22 makes them different from a SEPTA bus23 driver or a state employee.24
Again, I don't25 140 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 think we adequately described the process2 by which we use to create the panels.3 Barry touched on some of the metrics that4 we use to measure the medical care5 delivered. You know, CompServices as a6 company will process about $100 million7 worth of medical on an annual basis. The8 City represents maybe 18 percent of that.9 So we're pulling -- I have a10 lot of medical data to pull, get11 statistics, find out the average cost per12 claim and average number of visits per13 claim, et cetera. The follow-up ratio14 that Dr. Bonner mentioned, we keep all15 those statistics, and they're shared on a16 regular basis, and it's usually every17 fiscal year or every other fiscal year18 we'll meet with the City to discuss19 whether or not there's any changes20 necessary to the panels, and it's --21
I22 understand. Just in generality, why23 would an agency -- why would you be able24 to send an employee from a25 141 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 quasi-governmental agency like SEPTA2 that's in the same financial binds as the3 City as opposed to being able to send the4 City employee? I mean, if these5 providers are capable of handling a6 PennDOT worker or a SEPTA worker or a7 DRPA worker -- I don't know if you do8 them or not, but my point is, what is so9 special about the City that they've lost10 the opportunity to do them?11
The honest answer12 is that it's client dependent. I mean,13 the Commonwealth may have different needs14 than the City has. SEPTA has different15 needs than the City has. And that16 meeting that occurs to make up the panels17 goes differently depending upon the18 client.19
But in20 fairness -- I know we're talking about21 people and their health and everything22 else, but in fairness, it all comes down23 to the cost of providing that, and you24 would think that an agency like SEPTA,25 142 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 which is in as strict financial straits2 as any other governmental agency in the3 Commonwealth, it seems that if these4 folks are able to take those referrals,5 what makes the City workers so different?6
We have7 different kinds of injuries and people8 have different job descriptions, and9 so --10
I mean, the11 injuries are different in that -- I mean,12 obviously, thankfully, SEPTA bus drivers13 don't get shot. That one I got.14
And the job that19 they need to go back to is a very -- has20 very different physical requirements, and21 so some therapy sites are better equipped22 to handle certain kinds of injuries and23 to return people to certain job24 requirements than others.25 143 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
I mean, I2 just -- I mean, this is certainly one3 hearing. We may have another. We may4 have more discussion, and certainly no5 one here sitting at this panel is an6 expert on this issue, but there seems to7 be a lot of inconsistency in what8 decisions are made and how they're made,9 and that's the concern that this10 Committee has, is that -- I mean, one of11 the things, Doctor, that you said earlier12 was that no physical therapy company13 should have a 25 or 30 percent dependence14 on an entity like the City of15 Philadelphia for their --16
I think I said17 they shouldn't depend on any single18 employer.19
Basically20 the same thing. I mean, but when I look21 at NovaCare with nine centers, I mean, I22 don't know their business model or their23 business information, I'm wondering what24 the percentage -- with nine locations, it25 144 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251 would seem that you would have a higher2 percentage of City work coming through3 their doors as opposed to anyone that's4 been removed thus far.5
I don't8 think they would tell you, but my point9 is that with nine locations, I mean,10 volume would indicate that --11
Well, we're12 hoping that the volume coming in the door13 is likely to stay the same, but what we14 are looking for is the number of15 follow-up visits to drop. And so that16 really is the concern. It's not about17 who comes in the door. It's about18 whether they stay for 15 years, and that19 really is the concern.20
And it's21 also 15 years' worth of prescriptions; is22 it not?23
I totally agree24 with you.25 145 11/17/10 - LEGISLATIVE OVERSIGHT - RES. 1007251
Well, then2 I would feel better if we were3 jettisoning some docs as opposed to4 jettisoning some -- or in addition to5 jettisoning the therapists, jettisoning6 the docs that write the scripts that send7 them there.8
All right.11 Good.12 Any other questions?13 (No response.)14
Thank you15 very much for your testimony and your16 attendance today. We will probably17 revisit this at some future date and18 we'll have recommendations that hopefully19 are forthcoming.20
Thank you for your21 questions, sir.22 (Committee on Legislative23 Oversight adjourned at 1:30 p.m.)24 - - -25 146 CERTIFICATE2 I HEREBY CERTIFY that the3 proceedings, evidence and objections are4 contained fully and accurately in the5 stenographic notes taken by me upon the6 foregoing matter on November 17, 2010, and7 that this is a true and correct transcript of8 same.9 10 11 12 13 --------------------14 MICHELE L. MURPHY15 RPR-Notary Public16 17 18 19 (The foregoing certification of this20 transcript does not apply to any reproduction21 of the same by any means, unless under the22 direct control and/or supervision of the23 certifying reporter.)24 25