Report 2009-107.2 Recommendations and Responses in 2015-041

Report 2009-107.2: California Department of Corrections and Rehabilitation: Inmates Sentenced Under the Three Strikes Law and a Small Number of Inmates Receiving Specialty Health Care Represent Significant Costs

Department Number of Years Reported As Not Fully Implemented Total Recommendations to Department Not Implemented After One Year Not Implemented as of 2014-041 Response Not Implemented as of Most Recent Response
California Correctional Health Care Services 5 5 3 2 1
California Department of Corrections and Rehabilitation 5 6 5 4 1

Recommendation To: Correctional Health Care Services, California

To determine whether the additional expansion of telemedicine is cost-effective within the California correctional system, Prison Health Care Services should further analyze the cost-effectiveness of telemedicine through a more robust estimate of savings, including considering factors such as the percent of telemedicine consultations that required subsequent in-person visits because the issue could not be addressed through telemedicine.

Response

The institution utilization management teams follow a standardized process to approve referrals and determine appropriateness of telemedicine services before the consultation. The cost effectiveness of telemedicine in prison health care has been shown through an analysis of medical guarding and transportation costs from 2013-2014. The analysis showed a cost avoidance of $7,222,574 based on 19,351 telemedicine encounters. For 2014-15 the figure is closer to $8.9 million in cost avoidance based on 23,900 specialty encounters, which reflects a 64 percent statewide utilization of Telemedicine. (see attachments)

An analysis looking at the percent of telemedicine consultations requiring subsequent in-person visits because the issue could not be addressed through telemedicine is not applicable as a traditional, in-person visit may still be needed for a specific physical examination, diagnostic studies or procedure. These visits can then be followed by a telemedicine visit for follow up. For example, a patient may be followed in Telemedicine by dermatology for a full year before the dermatologist decides, based upon a morphological change observed on a dermatology camera, that a wide-margin excision of a lesion is indicated. The telemedicine cost savings for that entire year remain actual savings and are unchanged based on the later surgical excision.

There are also times where the specialist prefers to see the patient face-to-face initially, which are then followed by telemedicine visits. The cost savings for the telemedicine follow-ups is unaltered by face-to-face visit. In addition, specialty encounters may be scheduled offsite due to the unavailability of a specialty provider network, or compliance date requirements. According to the American College of Physicians, Policy Recommendations to Guide the Use of Telemedicine physicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient.

Recommendation To: Corrections and Rehabilitation, Department of

To better communicate to policy makers the annual cost of incarceration, and to provide a more accurate estimate of expenditures associated with changes in the large leave balances of custody staff—many of whom require relief coverage when they are absent—Corrections should provide a calculation of the annual increase or decrease in its liability for the leave balances of custody staff to better explain the cause of changes in expenditures to the relevant legislative policy and fiscal committees.

Response

Each year, CDCR's Budgets Management Branch must submit its overall budget projections to both the Legislative Finance Committee and the Department of Finance for review and approval before including into the final annual Governor's Budget. For these expenditure projections, CDCR's Budgets Management Branch completes detailed calculations including vacant position coverage and custody leave coverage, and associated salary increases as part of the overall Salaries and Wages line item category. The Salaries and Wages projections are part of the overall CDCR budget projections submitted for approval into the final annual Governor's Budget. The attached spreadsheet outlines the detailed calculations supporting the summary line items on the Governor's Budget submittal.

Overall, for FY 14-15, leave liability for all "custody classifications", which we interpreted as BU6 staff, decreased by $70.2 million or 9.1% from June 30, 2014 to June 30, 2015. (detail by month attached)

Recommendation To: Corrections and Rehabilitation, Department of

To better communicate to policy makers the annual cost of incarceration, and to provide a more accurate estimate of expenditures associated with changes in the large leave balances of custody staff—many of whom require relief coverage when they are absent—Corrections should provide an estimate of the annual cost of leave balances likely to be paid for retiring custody staff to the relevant legislative policy and fiscal committees.

Response

As part of the annual projections for the Governor's Budget, CDCR's Budgets Management Branch completes detailed lump sum calculations for possible employee separations to include in the overall Salaries and Wages projections. The Salaries and Wages category includes possible salary increases, temporary help and overtime as part of the Vacant Position coverage to fill behind those separations. The Salaries and Wages projections are part of the overall CDCR budget projections submitted to both the Department of Finance and the Legislative Finance Committee for approval into the final annual Governor's Budget. The attached spreadsheet outlines the detailed calculations supporting the summary line items on the Governor's Budget submittal.

Based on historical trends and current staff for FY 2015-16, lump sum for custody positions, again interpreted to mean BU 6 staff, is estimated to be approximately $103 million. (details attached)

Recommendation To: Correctional Health Care Services, California

To determine whether the additional expansion of telemedicine is cost-effective within the California correctional system, Prison Health Care Services should identify and collect the data it needs to estimate the savings of additional telemedicine through an analysis of the cost of specialty care visits currently provided outside of the institution that could be replaced with telemedicine.

Response

CCHCS has partially implemented this recommendation with full implementation anticipated in fiscal year 2016/2017.

All 35 prisons have telemedicine capability and access to telemedicine specialists. For telemedical appropriate encounters, telemedicine services specialty claims data indicate that Telemedicine is utilized statewide at 64 percent in 2015 for an estimated medical guarding and transportation cost avoidance of $8,915,000 at fiscal year-end (June 2015). This is up from 48 percent in 2011, 55 percent in 2012, 59 percent in 2013, and 61 percent in 2014. This data indicates that those specialty services that could be accomplished via telemedicine (non-procedural office visits in specialties Telemedicine Services offers) have shown a steady increase in the last five years.

Achieving the remaining 36 percent is estimated to potentially save an additional $4,977,000 in medical guarding and transportation cost avoidance. The telemedicine specialty network continues to expand around the needs of the institutions; however, the expansion of the telemedicine specialty network in some areas (e.g., Pelican Bay State Prison) remain challenging for those surgical specialties and subspecialties that may eventually require a "hands on" visit, thus making a 100 percent capture rate more difficult to attain.

The ability to further analyze telemedicine specialty care data within CCHCS will be realized with the completed roll out of the statewide electronic medical record currently in deployment. Additionally, with the implementation of the electronic health record system, CCHCS will employ a complete care model that will allow for a higher level of care coordination and is expected to result in an increase in specialty referrals routed for telemedicine services versus offsite services. For this reason, CCHCS targets full completion of this recommendation by December 2016.

Recommendation To: Corrections and Rehabilitation, Department of

To address the erroneous sentencing information and inappropriately assigned convictions in its data system, Corrections should complete its cleanup of data that will be transferred into the new system, ensuring that this review includes a detailed evaluation of convictions that have been assigned outdated sentencing information as well as deleting erroneous sentencing information, before it begins using its new data system.

Response

As reported in October 2013, the EIS/SOMS portion of the action plan has been complete since August 2013. Efforts are continuing by the Division of Adult Institutions (DAI) Case Records staff to work through data identified as needing review and correct.

Recommendation To: Corrections and Rehabilitation, Department of

To address the erroneous sentencing information and inappropriately assigned convictions in its data system, Corrections should create a schedule for regular checks of the accuracy of existing sentencing information, as well as the accuracy with which sentencing information has been assigned to convictions.

Response

The Case Records Administrator worked with SOMS to implement changes to the second striker credit earning formulas to address new statue rules. This is an ongoing maintenance activity that will be needed whenever statue or codes are revised to ensure the ongoing accuracy of sentencing information.This most recent example was completed in May 2014. Additionally, each offender is received into CDCR with a Commitment (Legal documents such as Abstract of Judgment, Minute Order, and/or Felony Compliant) at the time they are admitted. The first check is completed by a Case Records Analyst to ensure the sentencing information is accurate for the conviction. Each offender will have regular checks at specific audit time frames, which include transfer audits, 60-day audits, and parole audits. If a sentence is found to be inaccurate for a type of conviction, CDCR continues to refer those cases to the presiding court/judge for clarification.

Current Status of Recommendations

All Recommendations in 2015-041