Florida Department of Corrections
Michael D. Crews, Secretary

Goal 1-3: Provide constitutionally mandated inmate quality health care through cost-effective medical, dental, and mental health treatment.

Note: Legislative Budget Request 2, Increased Requirements for Acquired Immune Deficiency Syndrome (AIDS) Funding supports this goal.

During FY 1997-98, 2,700 health service staff members provided 2.8 million inmate health care encounters encompassing medical, dental and mental health services. It is paramount to understand that inmate health care is constitutionally driven. The challenge for the department is to provide quality mandated care in a cost-effective manner.

To provide constitutional health care to inmates that is cost-effective, the department will focus on these key initiatives:

• Strive to lower the inflationary increase of inmate health care per diem expenditure rate.
• Strive to decrease the daily cost of hospitalization for inmates requiring unique care found in community medical facilities.
• Enhance the productivity of the department's Health Services Providers.
• Enhance suicide prevention efforts.
• Improve efforts to lower inmate health care grievances.

The number of inmates with chronic illnesses and special medical needs such as community hospitalization affects the inmate expenditure rate the most. Inmate admission screenings show an increasing number of inmates with special needs and illnesses. Also influencing this constitutionally driven financial drain is the ever-increasing prison population represented by more violent or career criminals who will be serving 85 percent of their much longer sentences. As of June 30, 1991, there were 1,600 "special population" inmates in the Florida prison system. These inmates are in medical, physical, and mental health grade 4 (severe health problems or restrictions), and/or over 65 years of age. This "special population" is estimated to increase from 3.5 percent of the inmate population in 1993 to 3.8 percent over the next five years. This is a 27 percent increase in this "Special Inmate Population," or an expected 669 more inmates with severe health problems or restrictions from 1998 through 2002 that will consume a high level of health care resources.

Five-Year Projection of "Special Inmate Population" Years 1998-2000
1998	1999	2000	2001	2002	2003	2004
2,486	2,689	2,850	3,003	3,155	3,307	3,460

The per diem health care cost for Florida inmates increased from $8.63 in FY 92-93 to only $9.30 in FY 97-98, a hard-fought annual average increase of only 1.3 percent. The department achieved this cost containment despite an increasing inmate population and by absorbing price increases for the last six years. For comparison, the Hospital and Related Services (HRS) component of the Consumer Price Index averaged 5 percent per year for the same period. The current $9.30 figure does include costs for the AIDS/HIV, cardiac, and cancer-the three most expensive illnesses to treat. Based on existing results, the department is confident its objective to monitor overall inmate health care expenditures and analyze those results against inmate health care processes will result in continuous process improvement.

Our second initiative, targeting inmate daily hospitalization health care costs in community hospitals, aims at saving Florida taxpayers money. There are times that an inmate's medical condition will exceed the department's internal medical capabilities. When an inmate enters a community hospital as an emergency or otherwise, it is an expensive proposition. The statewide department contracted average daily community hospital cost is $1,800, including physician charges. However, comparing this cost to a statewide non-contracted cost of $2,650 (hospital charges only) our 68 percent reduced cost is a result of aggressive cost-saving efforts despite a growing inmate population and many special medical, dental, and mental health needs. Unfortunately, the inmate health care average daily cost is slowly growing notwithstanding the department's best efforts. This table shows the incremental increases:

Total Major Institutions Average Daily Inmate Health Care Costs For Last Five Years
FY 93-94	FY 94-95	FY 95-96	FY 96-97	FY 97-98
$8.25	$7.91	$8.24	$8.81	$9.30

HIV/AIDS costs which are included in the above average daily costs are shown are here separately identified as an average daily inmate HIV/AIDS health care cost and shown below for last five years

HIV/AIDS Average Daily Inmate Health Care Costs
FY 93-94	FY 94-95	FY 95-96	FY 96-97	FY 97-98
$0.38	$0.39	$0.34	$0.48	$0.77

The significant increase in average daily costs for HIV/AIDS in Fiscal Year 97-98 is primarily attributable to the anti-retro viral medications used in accord with US Public Health Centers for Disease Control and Prevention standards of health care for persons with HIV/AIDS. One way we are striving to control these high costs is through close coordination and working arrangements with medical colleges. At this time, the department has three HIV/AIDS physicians that clinically manage significantly ill inmates at Central Florida Reception Center at no cost to the department. The University of Miami, Brown University, and Yale University all provide the department with physicians at no cost to Florida taxpayers. We expect these positive clinical and cost-effective academic and professional relationships to continue to grow into even greater future benefits.

The department focuses on inmate community hospitalization costs through these two processes:

• Negotiated Contracts: The department negotiates a "best price" with regionally centralized community hospitals. In addition, the department attempts to negotiate a favorable price with the community hospital closest to the correctional institution for those occasional emergency care situations.
• Utilization Management Program: This team manages the hospitalization of inmates statewide. They assure community hospital cost-effectiveness through analyzing and approving each inmate patient's need for external hospitalization.

The steady decline of Inmate Community Hospital Bed Days speaks to the effectiveness of these two initiatives.

Community Hospital Bed Days Per 1000 Inmates: Selected Years
FY 92-93	FY 93-94	FY 94-95	FY 97-98
188.2	186.3	140.0	130.9

Inmates with mental disorders that require monitoring and treatment represented 8.2 percent of the prison population in 1993 and in 1998 represented 13.2 percent of the inmate population. Unfortunately, this statistic does not capture those severely disturbed who may attempt suicide. Suicide is a high departmental focal point because preventing untimely death is a principle of the Office of Health Services.

Suicide is always a prime departmental concern, however, it is not an out-of-control health services issue. This is especially true when the department is compared to the national correctional average suicide rate as noted in this data.

DC and National Suicide Rates Per 1000 Population During Last Five Years.
	FY 93-94	FY 94-95	FY 95-96	FY 96-97	FY 97-98
IN FLA DC	.15	.10	.09	.06	.09
ALL US DCs	.124	201	.162	No Data	No Data

Including in the Agency Strategic Plan an objective on suicide underscores the department's commitment to track such events and meticulously analyze them to improve our prevention efforts.

Within the health services provider arena, the physicians, dentists, psychologists, and nurses are the most expensive resource. Management of their productive time is critical to cost-savings.

To enhance the time management of the department's health services providers, consolidation plans have been proposed to best utilize these expensive staff resources in the most productive and cost-effective ways. A recent focus on dentists includes an initiative that geographically consolidates delivery of dental care. Taxpayers realized $2.5 million in cost avoidance from this consolidation that also simultaneously produced a 7.7 percent dental productivity increase.

There are lucrative benefits to tracking health services providers' productivity units and by the department's efforts to do so should assure taxpayer dollars produce maximum return on investment. Dentists' productivity units are the first major focus at this time.

The monitoring of inmate health service grievances is an internal indicator of whether the institutional health care process is functioning properly. By reviewing all grievances, management begins analysis of whether or not the delivery process is within its upper and lower control limits. Focusing exclusively on the "upheld" grievances should reveal further opportunities for improvement of the medical, dental, and mental health delivery of care to inmates.

Total Grievances and Upheld Grievances.
FISCAL YR	1995-96	1996-97	1997-98
TOTAL	2980	3624	4700
# UPHELD	67	58	78
% UPHELD	2.2%	1.6%	1.7%

The grievance bottom line is to spend less time chasing grievances and focus upon delivering constitutionally mandated quality health care for inmates to prevent the spread of disease which ultimately protects the general public health of Floridians.

Objective 1-3.1

Increase cost effectiveness by striving to lower the average percentage increase in expenditure rate for health care per inmate at or below the average annual percentage increase in the Hospital and Related Services (HRS) Component of the Consumer Price Index annually.

Strategies:

1. Identify physical and mental health needs of inmates to provide appropriate health care interventions, and promote good health practices. Lead Unit: Health Services
2. Promote inmate health education opportunities to increase their responsibility for personal health. Lead Unit: Health Services
3. Continue cost-effective consolidation of health services delivery including applications of "Managed Health Care" practices suitable for quality correctional health care. Lead Unit: Health Services
4. Prevention interventions will be considered for implementation by management. Lead Unit: Health Services
5. Increase capabilities to provide health care services internally to provide both improved quality and cost-effectiveness. Lead Unit: Health Services
6. Continue to identify and implement additional health services quality and cost beneficial partnerships with community health care providers, schools with health care specialties, and other state and county agencies. Lead Unit: Health Services
7. Pursue partnerships with community health agencies to achieve cost-savings. Lead Unit: Health Services

Objective 1-3.2

Strive to decrease the contracted average daily cost of community hospitalization to 80% of the average daily Florida hospitalization charges statewide (FY 96-97) for acute care as reported to the Agency for Health Care Administration.

Strategies:

1. Negotiate optimum per diem rates and percentage reduction of charges from hospitals not on a per diem basis. Lead Unit: Health Services
2. Improve management of community hospitalization to assure appropriate utilization of hospital and infirmary resources through the Utilization Management Program team. Lead Unit: Health Services
3. Identify seriously ill and chronic disease patients and move to appropriate departmental facilities. Lead Unit: Health Services
4. Provide physician education on emerging treatments for debilitated inmate patients, such as those with AIDS. Lead Unit: Health Services
5. Continue clustering inmate patients within special facilities and designate specialty centers of excellence for treatment of specific diseases or injuries. Lead Unit: Health Services
6. Review all community hospital charges and physicians fees for any unnecessary treatments and hospitalization and deny payment of charges to such hospitals and providers of health care. Lead Unit: Health Services
7. Review of current national and community health care standards and practices. Lead Unit: Health Services

Objective 1-3.3:

Continue cost effectiveness of dental providers by maintaining and where possible increasing the average Dental Productivity Units per dental provider day at or above 22.9 baseline (FY 96-97).

Note: The American Dental Association defines Dental Productivity Units by identifying each dental procedure and assigns a time value of 17 minutes to it. Therefore, an eight hour day produces 28.2 dental units. Due to stringent security demands, institutional dentists produce a minimum of 22.9 units.

Strategies:

1. Continue redefining dental staffing profiles at each institution. Lead Unit: Health Services
2. Where feasible consolidate dental services. Lead Unit: Health Services

Objective 1-3.4:

Strive to reduce inmate suicides below the baseline rate of 0.06 (FY 96-97) per 1000 of the total inmate population annually.

Strategies:

1. Enrich screening of all inmates received into custody for indicators of potential suicidality. Lead Unit: Health Services
2. Enhance continuous monitoring of inmates for indicators of potential suicidality. Lead Unit: Health Services
3. Mortality Review team to review, analyze, identify trends, and make recommendations regarding each suicide. Mortality Review team to review, analyze, identify trends, and make recommendations regarding each suicide. Lead Unit: Health Services
4. Conduct comparative analysis between state correctional systems and population at-large. Lead Unit: Health Services

Objective 1-3.5:

Strive to reduce approved inmate health care grievance appeals to below the baseline rate of 1.6% (FY 96-97) of the total health care grievances annually.

Strategy

Health Services Quality Management Committee analyzes grievances, identifies trends, and recommends appropriate interventions. Lead Unit: Health Services.