THE MISSISSIPPI LEGISLATURE

The Joint Committee on

Performance Evaluation and Expenditure Review

Report # 507

Medical Care for State Inmates: The Department of Corrections’ Contract Management and Its Provision of Specialty Medical Care

Executive Summary

Introduction

To address legislative concerns regarding the Mississippi Department of Corrections’ (MDOC’s) management of state inmates’ medical care, including management of the contract with Wexford Health Sources, Inc., and the department’s own provision of specialty medical care, PEER reviewed the following areas of concern:

• the risk to the state related to both hidden costs and care for inmates associated with the Department of Corrections’ decision to change the scope of services that had traditionally been required of its medical services contractors;
• whether the contractor, Wexford Health Sources, met minimum standards for routine medical care as set out in the contract with MDOC for medical care provided to state inmates;
• MDOC’s assurance of the provision of chronic care, including mental health care;
• MDOC’s provision of specialty medical care; and,
• MDOC’s and Wexford’s operational issues while providing inmate medical care.

The review focuses on whether MDOC’s current medical services program complies with accepted standards promulgated to assure the quality of medical care provided to persons under control of the state’s correctional system, including assurance of timely and appropriate access to health care providers and services.

PEER sampled inmates’ medical records dated between January 1, 2007, and May 31, 2007, and limited the review to the medical records of inmates housed at one of the three main correctional facilities (Central Mississippi Correctional Facility [CMCF], South Mississippi Correctional Institution [SMCI], and Mississippi State Penitentiary [MSP]), hereafter referred to as the “parent facilities.”

MDOC’s Contract for Inmate Medical Services

In July 2005, MDOC’s previous medical services provider, Correctional Medical Services, informed the department that it did not wish to be considered for renewal of its contract ending June 30, 2006, thereby necessitating that the department move forward with a search for a new medical services provider.

Following departmental evaluations of responses to a request for proposals, the Department of Corrections entered into a contract with Wexford Health Sources, Inc., in June 2006 for FY 2007 through FY 2009 for a total of $94,312,523. The contract requires that Wexford meet all national standards (the American Correctional Association [ACA] and the National Commission on Correctional Health Care [NCCHC]) for inmate medical care.

The contract between MDOC and Wexford includes inmate medical services for the three major correctional facilities, the eleven satellite facilities (also known as regional facilities), seventeen community work centers, three male restitution centers, and the Governor’s Mansion work site. The contract with Wexford does not include the state’s private correctional facilities or county regional correctional facilities. Inmates are transported to one of the three parent facilities for medical care.

The type of contract MDOC entered into with Wexford is for a “combination” model for delivery of medical services to inmates. Under this model, the contractor assumes responsibility for medical care rendered inside institutions, with the correctional agency taking responsibility for important functions such as specialty care rendered outside of the correctional institutions and utilization review. This enables the correctional agency to manage the care given to the inmates, but exposes the correctional agency to additional financial and managerial risks, as the agency becomes responsible for providing certain forms of care.

In entering into the current agreement with Wexford, the department has assumed for the state an increased risk, as the department is now required to bear directly a greater share of the responsibility for delivering medical care to inmates. As the state assumes greater responsibility and control over the delivery of services, it has more opportunities for both controlling expenses and better managing the delivery of care. However, the state must ensure that quality specialty medical care is provided to inmates and that this care can be rendered to inmates in a manner that will not overly extend the state’s financial resources.

Access to Medical Care Provided by Wexford

Based on PEER’s compliance review with medical service contract standards, from January 1, 2007, through May 31, 2007, the Department of Corrections and its contractor, Wexford Health Services, did not ensure that all inmates received timely and adequate access to quality medical care.

To determine the quality of medical care state inmates received from January 1 through May 31, 2007, PEER reviewed samples of medical records at each of the three parent facilities for compliance with standards of the medical services contract with Wexford and for compliance with accepted national standards regarding routine and chronic care, including mental health care.

Routine Medical Care for Inmates

During the period of review, MDOC and its contractor Wexford did not ensure that all state inmates received timely access to the sick call process and two-year dental prophylaxis within the intervals established by the medical services contract and by national correctional standards for medical care. Wexford did comply with applicable standards for the medical care component of the inmate intake process.

According to MDOC’s medical services contract with Wexford Health Sources, Wexford is responsible for all routine medical care for state inmates at the three parent correctional facilities.

PEER analyzed the following areas of routine medical care during the period of review:

• the medical care component of the inmate intake process;
• the sick call process; and,
• the two-year dental prophylaxis.

According to the contract, Wexford must ensure timely access to routine medical care by meeting at least an 85% compliance rate for the three medical services contract areas listed above. Failure to meet at least an 85% compliance rate could subject Wexford to predetermined contractual financial penalties, hereafter referred to as liquidated damages, as dictated by the contract.

Exhibit A below summarizes Wexford’s compliance with standards at CMCF, SMCI, and MSP for routine medical care. As shown in the exhibit, during the period of review, Wexford complied substantially with contract standards and national correctional standards in regard to ensuring that state inmates received adequate access to health care upon intake into the state correctional system. However, Wexford did not ensure that all inmates had timely access to medical care through the sick call process in accordance with contract requirements and national correctional standards. Also, Wexford did not document whether all inmates had a dental prophylaxis every two years in accordance with contract requirements.

Exhibit A: Summary of Wexford’s Compliance with Standards for Routine Medical Care at the Three Parent Correctional Facilities, January 1 through May 31, 2007

SOURCE: PEER analysis of MDOC’s inmate medical records.

Chronic Medical Care for Inmates

MDOC’s current contract with Wexford does not address the issue of chronic care. Thus MDOC cannot ensure that Wexford develops and implements a system of quality chronic medical care for the state’s inmates.

Although Wexford provides chronic care to inmates, since MDOC’s medical services contract with Wexford does not address chronic care, MDOC does not audit chronic care for the same 85% compliance rate as the other medical areas and does not assess liquidated damages regarding chronic care. Therefore, in assessing Wexford’s performance in providing chronic care, PEER used Wexford’s policies and procedures, MDOC’s policies and procedures, and national standards as the compliance standards.

PEER assessed Wexford’s compliance with providing timely access to quality chronic care for state inmates in the correctional system for the following areas:

• chronic care visit at least every six months;
• notation in the medical records of scheduling a follow-up chronic care visit in six months; and,
• a medication treatment plan for each inmate under chronic care.

Exhibit B below summarizes Wexford’s performance regarding chronic care at CMCF, SMCI, and MSP. As shown in the exhibit, during the period of review, Wexford did not comply with its own policies and procedures regarding timely access to chronic care and proper documentation of all chronic care follow-up referrals. However, Wexford did comply with documentation of a medication treatment plan requirement.

Exhibit B: Summary of Wexford’s Performance Regarding Chronic Medical Care at the Three Parent Correctional Facilities, January 1 through May 31, 2007

*MDOC’s medical services contract with Wexford did not address chronic medical care, although Wexford does provide chronic care services to the three parent correctional facilities.

SOURCE: PEER analysis of MDOC’s inmate medical records.

Mental Health Care for Inmates

MDOC does not require that Wexford keep mental health records organized separately from the inmates’ other medical records, a condition that could affect continuity of care.

Wexford staff do not consistently file mental health records with records for chronic care. Critical mental health information may be overlooked by medical personnel due to their inability to locate such information within the inmates’ medical records.

Also, for both chronic and mental health care, MDOC has not required Wexford to develop an effective system-wide method of managing inmates’ appointments or maintaining uniform log sheets. As a result, MDOC cannot assure continuity of care.

Wexford’s and MDOC’s Provision of Specialty Medical Care

Inmates’ medical records from January 1, 2007, through May 31, 2007, do not contain documentation that MDOC and its contractor Wexford provided timely specialty medical care to all state inmates needing such care.

According to MDOC’s medical services contract with Wexford, Wexford and MDOC share responsibility for providing inmates with access to specialty medical care. As of July 1, 2006, Wexford is responsible for providing the following specialty care: optometry, radiology, dialysis, audiology, and care for sexually transmitted diseases, HIV/AIDS, and tuberculosis. MDOC is financially responsible for all other specialty care services for state inmates off site and is responsible for oversight of the utilization review process for specialty care for all state inmates.

PEER reviewed MDOC’s and Wexford’s implementation of their respective responsibilities for inmates’ specialty medical care from January 1, 2007, through May 31, 2007, and concluded that MDOC and Wexford did not document timeliness of specialty care for all inmates during that period because neither Wexford nor MDOC has established written timeliness standards for monitoring consult requests. Also, neither Wexford nor MDOC has implemented an effective method of tracking inmates through the specialty care process.

Operational Issues: MDOC and Wexford

During PEER’s review of inmate medical records to determine the quality of medical care state inmates received, PEER identified operational issues that also affect quality of care:

• medical staffing;
• quality assurance and recordkeeping; and,
• MDOC’s medical expenditures.

PEER also compared MDOC’s FY 2007 medical costs under the contract with Wexford to the correctional system’s FY 2006 costs for medical care.

Issues with Medical Staffing

For the period of review, PEER noted the following deficiencies in the medical staffing of the correctional facilities:

• Wexford’s medical staffing levels were not in compliance with the contract requirements. Neither MDOC nor Wexford could ensure appropriate and timely access to quality medical care for state inmates because of staff shortages.
• MDOC did not require Wexford to submit documentation of all licensures, certifications, and registrations of all medical staff to MDOC for review. Without providing any type of oversight, MDOC relied on Wexford to ensure that its medical personnel were properly licensed, certified, or registered in the state of Mississippi. As a result, during the period of review at least five individuals without proper credentials provided medical care to inmates.
• Neither MDOC nor Wexford ensured sufficient orientation/training of temporary medical staff. Although Wexford has an orientation program in place for newly hired full-time medical staff, MDOC did not require in contract that Wexford provide temporary nursing staff (“agency nurses”) with basic orientation relative to provision of medical care in a correctional environment.

PEER also determined that MDOC has not collected liquidated damages for Wexford’s failure to meet staffing requirements of the contract. Although as of June 30, 2007, the MDOC Chief Medical Officer had recommended assessment of over $1 million in liquidated damages, of which $931,310 was incurred due to staffing shortages, MDOC management has not formally assessed or collected any liquidated damages from Wexford to recoup state funds paid for staffing that was not provided.

Issues with Quality Assurance for Contract Compliance and Recordkeeping

During the period of review, neither MDOC nor Wexford had a quality assurance program for contract compliance in place that ensured timely access and continuity of medical care through accurate and appropriate medical recordkeeping. The major areas of concern associated with quality assurance and medical recordkeeping are as follows:

• Neither MDOC nor Wexford has an effective quality assurance process. Wexford does not have a quality assurance plan in place that ensures that the MDOC Health Service Administrator receives accurate medical compliance data from Wexford’s databases to use in conducting compliance audits. Also, MDOC did not establish in its contract with Wexford a formal audit methodology that utilizes confidence levels and compliance ranges and includes all contracted medical service areas. Therefore, MDOC cannot ensure that all state inmates receive timely access to quality medical care.
• Significant percentages of inmates’ medical records lack critical medical information. Wexford does not have a quality assurance program in place that ensures that all medical records are accurate and can be used to make timely decisions in regard to state inmates’ medical care.
• Wexford does not assure confidentiality in the transport of inmates’ medical records. Wexford does not ensure that all medical records and medications are sealed at the time of inmate transport from one correctional facility to another.

MDOC’s FY 2007 Medical Expenditures

MDOC spent approximately $42.8 million for inmate medical care in FY 2007, approximately $1.1 million more than it would have expended for Wexford’s turnkey proposal to provide comprehensive medical services to inmates and approximately $2.8 million more than its FY 2007 appropriation for medical services.

In addition to paying Wexford approximately $30 million for providing routine medical care, the department incurred expenses of approximately $12.8 million for providing specialty medical care for inmates. By opting to use the combination model of service delivery, the department expended approximately $42.8 million, or $1.1 million more than it would have if the department had accepted Wexford’s turnkey proposal.

MDOC’s FY 2007 appropriation bill included spending authority for $40,011,620 to operate the department’s medical services program. In spending approximately $42.8 million on medical services, the department exceeded its FY 2007 spending authority by approximately $2.8 million.

According to staff of the Department of Finance and Administration, as of October 3, 2007, MDOC had exceeded its total FY 2007 spending authority by approximately $5.2 million, with $2.8 million of that amount attributable to medical services. To cover the $5.2 million that it overspent during FY 2007, the department used a portion of its FY 2008 appropriation. This practice violates MISS. CODE ANN. Section 27-104-25 (1972), which states that an agency may pay a claim from a prior fiscal year if the claim is presented within one year, if the claim does not cause the agency to exceed its prior year’s appropriation bill, and if sufficient funds remain in the current year’s allotment—i. e., appropriation amount—to pay the claim. Because the department had a balance of $1.7 million remaining from its FY 2007 appropriation, the department did not have sufficient funds remaining to offset the $5.2 million that it overspent in FY 2007.

Recommendations

1. The Mississippi Department of Corrections staff should seek to amend the department’s medical services contract to require Wexford to:
   
   
   • use a uniform method (such as a date stamp) by which qualified personnel document the date of receipt of inmates’ sick call requests and the date on which such sick call requests are triaged. Documentation should include verification by the initials or signature of the person receiving the request or conducting triage;
   • document the required two-year dental prophylaxis in an inmate’s dental records;
   • provide a system of chronic medical care for inmates, incorporating standards of the American Correctional Association and National Commission on Correctional Health Care for inmates’ chronic medical care;
   • establish in writing acceptable time frames for submitting specialty consult requests to MDOC’s Office of Specialty Care. For those consult requests that fall outside the acceptable time frame, Wexford should include notations on the inmate’s medical record regarding the status of the request and an explanation of the delay;
   • segregate mental health records within an inmate’s medical records by use of a separate tab;
   • develop and utilize a uniform management information system for logging chronic and mental health care, including, at a minimum, inmate name and number, facility location, date, type of condition;
   • design and implement a computerized management information system that allows staff at all of the correctional facilities the capability to track and monitor inmates’ chronic care and mental health appointments;
   • submit to MDOC for review and final approval the names of all potential medical staff, accompanied by evidence of professional licensure, certification, and/or registration prior to their employment; and,
   • secure all health records in sealed boxes and all medications in sealed envelopes prior to the transfer of inmates among correctional facilities. Also, the contract should require Wexford health care staff and MDOC transportation officers to sign off on the transfer record that lists all the medications the inmate has en route, the number of pills en route, and the number of doses en route. Upon arrival at the receiving correctional facility, Wexford health care staff should inventory the contents of the inmate’s medication envelope to ensure that the contents reconcile with those listed on the transfer record.
2. The Mississippi Department of Corrections staff should ensure that Wexford conducts triage seven days a week at all correctional facilities as is presently required in the contract.
3. The Mississippi Department of Corrections staff should develop and adhere to written timeliness standards for monitoring the actions that the department should take during the portion of the specialty care process that is within the parameters of the department’s responsibility. For example, MDOC should establish an acceptable time frame for reviewing consult requests upon receipt from the contractor and scheduling specialty appointments and surgeries. Then, for those consult requests that fall outside the acceptable time frame, MDOC should include notations on the inmate’s medical record regarding the status of the request and an explanation of the delay.
4. MDOC should create a management information system accessible to medical and dental providers and directors at Central Mississippi Correctional Facility, South Mississippi Correctional Institution, and Mississippi State Penitentiary. This system should incorporate action standards for the completion, submission, receipt, and review of consult requests and the scheduling of appointments and surgeries, and should trigger an alert to responsible personnel if the status of an inmate’s case is not checked within a reasonable time frame, as established by Wexford and MDOC in their timeliness standards. These standards should account for the possibility of Wexford’s or MDOC’s need to obtain additional information before making decisions regarding the request and the response time needed for such, as well as the department’s prioritization of requests.
5. Wexford should periodically provide MDOC staff with documentation of its formal recruitment plan to attract and retain appropriately licensed health care staff.
6. MDOC should require Wexford to develop a strategy for ensuring that all agency nurses employed at one of the state’s correctional facilities receive basic orientation regarding provision of medical care in a correctional environment prior to assuming their duties.
7. For purposes of ensuring compliance with contractual requirements, MDOC should require Wexford to design and implement a verifiable management information system that ensures that reports submitted by Wexford to MDOC accurately reflect information recorded on source documents—e. g., sick call logs, chronic care logs.
8. MDOC should ensure that Wexford provides all necessary medical services and maintains all medical record documentation as required in its inmate medical services contract with the department. Also, in order to determine Wexford’s compliance with contract provisions, MDOC should develop a formal audit methodology that includes appropriate statistical sampling to allow the department to extrapolate the sample results to the entire population.
9. MDOC should make formal demand to Wexford for the collection of liquidated damages provided for in the contract for failing to adhere to contractual requirements.
10. The State Auditor should investigate the department’s overspending of its FY 2007 medical services appropriation and consider taking any necessary collection actions against MDOC personnel.

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