District of Columbia: Information on Health Care Costs (Letter Report,
04/22/96, GAO/AIMD-96-42).
Recent studies on the District of Columbia's health care system have
concluded that the city's health care problems are aggravated by such
social factors as high rates of poverty, crime, substance abuse, and
unemployment. These factors account for the sizable numbers of persons
who do not seek preventive health care and cannot pay for medical
treatment, the inappropriate use of D.C. General Hospital for primary
care, and the many trauma care patients at area hospitals. To help
Congress evaluate various restructuring proposals being considered for
the District, this report discusses the District's health care budget
and the composition of the District's health care system, including the
number of Medicaid recipients and uninsured and the distribution of
hospitals and clinics.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: AIMD-96-42
TITLE: District of Columbia: Information on Health Care Costs
DATE: 04/22/96
SUBJECT: Locally administered programs
Disadvantaged persons
Municipal governments
Health care cost control
Health centers
Hospitals
Mental care facilities
Facility repairs
Health services administration
Health care programs
IDENTIFIER: Medicaid Program
DC Financial Management System
District of Columbia
Medicaid Management Information System
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Cover
================================================================ COVER
Report to Congressional Requesters
April 1996
DISTRICT OF COLUMBIA - INFORMATION
ON HEALTH CARE COSTS
GAO/AIMD-96-42
District Health Care Costs
(901674)
Abbreviations
=============================================================== ABBREV
AFDC - Aid to Families With Dependent Children
CMHS - Commission on Mental Health Services
DHS - Department of Human Services
FMS - Financial Management System
HCFA - Health Care Financing Agency
HMO - health maintenance organization
ICF/MR - intermediate care facilities for the mentally retarded
DCHA - District of Columbia Hospital Association
MMIS - Medicaid Management Information System
NHC - neighborhood health clinic
PBC - Public Benefit Corporation
Letter
=============================================================== LETTER
B-265725
April 22, 1996
The Honorable James T. Walsh
Chairman
The Honorable Julian C. Dixon
Ranking Minority Member
The Honorable Rodney P. Frelinghuysen
Member
Subcommittee on the District of Columbia
Committee on Appropriations
House of Representatives
At your request, we are providing baseline information on the
District of Columbia's health care system to help evaluate the
various restructuring proposals the District is considering in light
of consistently rising health care expenditures, limited resources,
and pending legislative changes. Specifically, you asked us to
answer questions concerning the District's health care budget and the
composition of the District's health care system such as the number
of Medicaid recipients and uninsured and distribution of hospitals
and clinics. To respond to your questions, we looked at many aspects
of health care in the District. In doing so, we also identified
several additional issues that we thought would benefit your
deliberations. This letter and the accompanying appendixes discuss
those issues as well as respond to your specific questions.
Recent studies\1 on the District's health care system have concluded
that the District's health care problems are aggravated by social
factors, such as high rates of poverty, crime, substance abuse, and
unemployment in the city. Such factors, these studies found, in turn
contribute to (1) a certain segment of the population that does not
seek or obtain preventive health care and is unable to pay for its
health care, (2) the inappropriate use of D.C. General Hospital for
primary care services, and (3) a large number of trauma care
recipients at area hospitals. It is critical that any action taken
by the District also consider these social factors.
Throughout this report, we cite numerous figures for the District's
health care expenditures. We did not perform an audit to verify that
these figures were correct, but rather only summarized and performed
financial analyses of the information provided by District officials.
In some cases, we found discrepancies between figures cited in
reports with those maintained in District accounting records for data
that was supposed to be reporting the same thing. Also, in some
instances, we received conflicting information about program
expenditures from the same source. Wherever possible in this report,
we used figures as recorded in the District's accounting
records--Financial Management System (FMS)\2 --which were audited by
an independent accounting firm for fiscal years 1991 through 1994.
Fiscal year 1994 data was used, unless otherwise specified, because,
at the time of our review, complete information regarding fiscal year
1995 was not available.
--------------------
\1 Final Report of the Mayor's Blue Ribbon Panel on Health Care
Reform Implementation, February 1995; District of Columbia Health
Sector Analysis Final Report, Lewin-VHI, Inc., December 5, 1995; and
Final Report of the Mayor's Task Force on Long Term Strategies to
Improve the District of Columbia's Public Health Care Delivery
System, January 1994.
\2 FMS is the District's accounting system which tracks budget and
actual expenditures.
BACKGROUND
------------------------------------------------------------ Letter :1
The District's involvement with the health care system is extensive
and complex. The Department of Human Services' (DHS) mission is to
meet the health and welfare needs of individuals and families in the
District by ensuring the development and implementation of health and
social service policies. This is accomplished through the activities
of the following four separate commissions:
(1) The Commission of Public Health sets public health care policy,
administers the District's preventive care and alcohol and drug abuse
service programs, and provides health care services directly at D.C.
Village nursing home and the 11 neighborhood health clinics. D.C.
Village nursing home provides long-term care and neighborhood clinics
provide various services such as dental and pediatrics services to
many citizens who cannot afford to pay for health care.
(2) The Commission on Health Care Finance sets Medicaid program
policy, such as optional services that will be provided and changes
to its eligibility criteria. It also administers and finances the
Medicaid program.
(3) The Commission on Mental Health Services administers the
District's mental health care system, which includes the operation of
Saint Elizabeths Hospital, a 360-acre historic landmark.
(4) The Commission on Social Services processes applications to
determine applicants' eligibility for various social programs,
including Medicaid.
In addition to the activities of the four commissions, the District
also provides public health services to all District residents at
D.C. General Hospital public hospital.
On March 1, 1996, Mayor Marion Barry introduced to the D.C. City
Council legislation creating a public benefit corporation intended to
consolidate many of the functions just described above. The Mayor
stated that the corporation, which is intended to be financially
self-sustaining in the near future, will compete in the private
health care arena by (1) integrating District government health care
services, (2) emphasizing preventive care, and (3) dedicating D.C.
General Hospital to critical care and specialized medicine.
SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :2
To analyze the District's health care budget, Medicaid program, cost
of District medical services, the placement of health care
facilities, and the financial condition of District hospitals, we
-- performed detailed analyses of the District's FMS and the
Medicaid Management Information System (MMIS) database of
Medicaid claims processed during the period covered in our
review;
-- performed detailed analyses of patient information and
expenditures from D.C. General and Saint Elizabeths and the
audited financial statements for the 13 private hospitals;
-- reviewed Medicaid cost settlements and cost reports for
hospitals and long-term care facilities, federally required
Health Care Financing Agency reports, the District's cost
reimbursement method for the 11 public clinics, reports
analyzing and offering recommendations on the District's health
care system and on the uninsured, and literature on national
health care trends;
-- interviewed officials in the Mayor's Office, each of the
commissions under the Department of Human Services, the D.C.
Hospital Association, other private health care experts,
officials at all of the 13 private District hospitals, and
officials at First Health, the District's Medicaid claims
processor; and
-- performed numerous site visits, including visits to all of the
private hospitals operating in the District, D.C. General,
Saint Elizabeths, the District-run nursing home (D.C. Village),
several District operated public clinics, and one private
clinic.
We conducted our work between July 25, 1995, and December 15, 1995,
in accordance with generally accepted government auditing standards.
Appendix V provides further details of our scope and methodology.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :3
The District's health care expenditures\3 increased 25 percent from
fiscal years 1991 to 1994. In fiscal year 1994, the District's
health care expenditures totaled a reported $1.246 billion,
representing approximately 27 percent\4 of total District
expenditures for fiscal year 1994. Our review showed that four
programs--Medicaid, mental health, D.C. General Hospital, and public
health--accounted for $1.16 billion, or about 93 percent, of the
District's 1994 total health care expenditures and that the Medicaid
program alone contributed $768 million, or about 62 percent of all
health care expenditures.
Medicaid is the District's fastest growing health care program.
Medicaid program expenditures increased 53 percent over the 4 fiscal
years from 1991 to 1994, compared with a 52-percent increase in
Medicaid expenditures nationwide. Although expenditures for mental
health and D.C. General still represented about 20 percent of the
District's total health care expenditures in 1994, they have
decreased about 9 percent and 7 percent, respectively, since 1991.
Public health expenditures increased about 17 percent over the same
time period.
We also found the following:
-- The District does not collect much of the specific cost
information, such as the type and cost of services provided in
its MMIS system. This information is generally recognized as
vital for measuring and managing Medicaid and thus the District
is impaired in attempting to reliably know and control its
program costs. Although District officials stated that this
information can be collected from other sources, the data cannot
easily be converted into a usable form for data analysis.
-- Saint Elizabeths Hospital and its surrounding buildings are in
disrepair. Costs to renovate were estimated at $119 million in
1985, the most recent renovation information available. And,
resources needed to maintain the facility have not been
available for many years, thus accelerating deterioration.
-- The District government runs both the public hospital and the
public clinics, but it does not coordinate fully between D.C.
General Hospital, the hospital-run clinics, and the neighborhood
clinics. In addition, from fiscal years 1991 to 1994, the
District provided a total of $309 million in subsidies, $75
million of which was characterized as loans, to cover large
operating deficits. And, in fiscal year 1994, D.C. General
reported nearly $78 million in uncompensated care. Several
studies have called for closing D.C. General because of the
costs to renovate the facility, the hospital's inefficient
operations, and the concern over the quality of care provided.
--------------------
\3 Fiscal year 1994 data was used, unless otherwise specified,
because, at the time of our work, complete information regarding
fiscal year 1995 was not available.
\4 The District of Columbia Comprehensive Annual Financial Report,
Year Ended September 1994, reported total expenditures of $4.7
billion.
PURPOSE OF APPENDIXES
------------------------------------------------------------ Letter :4
Appendix I contains our responses to specific questions your office
asked about trends in the District's health care budget and actual
expenditures of health care and Medicaid programs, the financial
condition of District hospitals, statistics on Medicaid recipients
and the uninsured population, the cost of medical services, and the
placement of health care facilities.
Appendix II provides information on the additional issues that we
think would be beneficial to your deliberations on health care. It
provides additional information on Medicaid, Saint Elizabeths, public
health, and D.C. General Hospital--the four programs that constitute
the primary sources of the District's health care expenditures for
fiscal year 1994.
Appendix III contains specific recommendations from various
comprehensive studies of the District's health care system. It
includes the current status of the recommendations, which indicates
that, overall, very little action has been taken.
Appendix IV summarizes the results of a study of the District's
public sector health facilities--such as D.C. General and its
clinics--performed by the U.S. Public Health Service, Office of
Engineering Services. This study, referred to as the Deep Look
Survey, consisted of a site visit, an in-depth inspection of the
facilities, and follow-up recommendations with cost estimates. Our
summary describes the facility being studied, the problems cited, and
the costs to repair them.
AGENCY COMMENTS
------------------------------------------------------------ Letter :5
In commenting on a draft of this report, the Mayor of the District of
Columbia generally agreed with the findings and stated that the
report could be useful in evaluating the District's progress in
transforming its health care system. The Mayor also responded that
his proposed Public Benefit Corporation (PBC), legislation for which
was forwarded to the City Council on March 1, 1996, would serve as
the umbrella agency for providing cost-efficient health care for the
District. The Mayor listed key functions of the proposed PBC, which
include reorganizing D.C. General and the District's 11 community
health clinics into a 24-hour integrated delivery system and
consolidating health care systems such as pharmacy and information
systems to allow for better planning and linkages between public and
private health care resources. A copy of the Mayor's comments is
included in appendix VI.
---------------------------------------------------------- Letter :5.1
If you have any questions about the information in this report,
please call me at (202) 512-9510 or Deborah Taylor of my staff at
(202) 512-9395. Major contributors are listed in appendix VII.
Gregory M. Holloway
Director, Governmentwide Audits
RESPONSES TO QUESTIONS ON THE
DISTRICT'S HEALTH CARE SYSTEM
=========================================================== Appendix I
BUDGET QUESTIONS
QUESTION ONE
------------------------------------------------------- Appendix I:0.1
What were the District's total health care budget and actual
expenditures for each of the last 4 years and how were the budgets
allocated among the various programs and activities?
GAO RESPONSE
------------------------------------------------------- Appendix I:0.2
As shown in figure I.1, both the District's actual and budgeted
health care expenditures have experienced steady growth from fiscal
years 1991 through 1994.\1 Actual spending by the District for health
care programs grew 25 percent, from $997 million in fiscal year 1991
to $1.245 billion in fiscal year 1994. However, except for fiscal
year 1993, the District's health care budget did not keep pace with
District spending.
Figure I.1: Health Care Budget
and Actual Expenditures
1991-1994
(See figure in printed
edition.)
Source: District's Financial Management System and the DHS
Controller's office.
The District's Financial Management System (FMS) does not organize
health care programs into one health care budget. For our analysis,
we included about 97 percent of the District's health care related
programs---both the appropriated and nonappropriated funds. We did
not include certain miscellaneous items for which the District incurs
health care related expenses, such as police, fire, and corrections
department medical services. These items accounted for approximately
$44 million of expenditures for fiscal year 1994. Further, we did
not include employee-related health care benefits, such as health
care insurance and disability compensation. We considered these as
costs of employment rather than health care costs.
We segmented the District's health care system into the four largest
programs. The remaining programs were grouped together and
categorized as "other." Table I.1 compares the District's health care
budget and actual expenditures for fiscal years 1991 through 1994.
Table I.1
The District's Health Care Budget and
Actual Expenditures
(Dollars in millions)
Fiscal Fiscal Fiscal Fiscal
year year year year
Program 1991 1992 1993 1994
------------------------------ -------- -------- -------- --------
Medicaid
Budget $427 $513 $677 $727
Actual 501 589 680 768
Difference (74) (76) (3) (41)
Public Health
Budget 138 152 159 151
Actual 122 121 132 142
Difference 16 31 27 9
Mental Health
Budget 165 158 137 136
Actual 156 145 138 142
Difference 9 13 (1) (6)
D.C. General
Budget 99 108 93 81
Actual 117 128 103 108
Difference (18) (20) (10) (27)
Other
Budget 102 98 87 85
Actual 102 89 81 85
Difference 0 9 6 0
======================================================================
Total
======================================================================
Budget $931 $1,029 $1,153 $1,181
Actual $998 $1,072 $1,134 $1,245
======================================================================
Difference $(67) $(43) $19 $(64)
----------------------------------------------------------------------
Note: Budget amounts reflect the revised budget, which may have
included any supplemental budget amounts received.
Source: FMS and DHS Controller's office.
From fiscal years 1991 through 1994, spending for the Medicaid
program consumed an increasing share of the District's total health
care expenditures--from 54 percent of total health care expenditures
in fiscal year 1991 to 62 percent in fiscal year 1994. With the
exception of public health, the remaining portions of the District's
health care categories have decreased since fiscal year 1991.
--------------------
\1 At the time of our work, actual expenditures for fiscal year 1995
were not available.
QUESTION TWO
------------------------------------------------------- Appendix I:0.3
What were the District's Medicaid budgets and actual expenditures for
the last 4 fiscal years for which information is available? Provide
a detailed breakdown for fiscal years 1993 and 1994--the 2 most
current, complete years.
GAO RESPONSE
------------------------------------------------------- Appendix I:0.4
As shown in figure I.2, Medicaid expenditures increased 53 percent
from $501 million in fiscal year 1991 to $768 million in fiscal year
1994. Although the Medicaid budget also increased from fiscal year
1991 to fiscal year 1994, actual Medicaid spending exceeded the
Medicaid budget in each year during that period. Fiscal year 1993 is
the only year that Medicaid expenditures approximated the Medicaid
budget.
Figure I.2: District Medicaid
Program Budget and Actual
Expenditures 1991-1994
(See figure in printed
edition.)
Source: District's Financial Management System and the DHS
Controller's Office.
Historically, the three largest expenditures for the District's
Medicaid program have been for inpatient hospital services, nursing
facility services, and intermediate care facilities for the mentally
retarded (ICF/MR). During fiscal year 1994, these three Medicaid
services accounted for 72 percent of total Medicaid spending.
We analyzed the Medicaid Management Information System (MMIS)
database for the fiscal years 1993 and 1994, and through July 31,
1995. This database contains the District's Medicaid claim and
payment information. Since the 1995 data were incomplete, table I.2
shows the trend in spending for the three largest Medicaid
expenditures only for fiscal years 1993 and 1994.
Table I.2
Three Largest Medicaid Expenditures
(Dollars in millions)
Fiscal Fiscal
year Percent year Percent
Medicaid service 1993 of total 1994 of total
---------------------- -------- -------- -------- --------
Inpatient hospital $279 42 $349 45
Nursing facility 134 20 149 19
ICF/MRs 64 10 64 8
Other 190 28 217 28
==============================================================
Total 667 100 779\a 100
--------------------------------------------------------------
\a District officials could not reconcile total Medicaid payments per
MMIS to FMS-recorded expenditures for fiscal year 1994.
Source: First Health--Unaudited MMIS data.
Inpatient hospital services have historically been the single largest
Medicaid program expenditure and accounted for about 45 percent of
total Medicaid expenditures in fiscal 1994. From fiscal years 1993
to 1994, inpatient hospital expenditures increased 25 percent, from
about $279 million to $349 million.
Nursing facility services have historically been the second largest
Medicaid expenditure. While the elderly population of the District
historically accounts for about 10 percent of Medicaid recipients,
nursing facility services accounted for about 19 percent of total
Medicaid spending in fiscal year 1994. From fiscal year 1993 to
fiscal year 1994, nursing facility services expenditures increased 11
percent.
Expenditures for intermediate care services for the mentally retarded
(ICF/MR) have historically been the third largest Medicaid
expenditure. ICF/MR expenditures remained flat from fiscal years
1993 to 1994, totaling $64 million for both fiscal years.
QUESTION THREE
------------------------------------------------------- Appendix I:0.5
For Medicaid recipients, what are the most costly Medicaid services
in the District--for example, physicians visits, hospital stays,
trauma care, emergency care, acute care, long-term care, etc.? What
are the most costly services provided to the uninsured?
GAO RESPONSE
------------------------------------------------------- Appendix I:0.6
Based on our analysis of Medicaid claims processed through the MMIS,
the two categories of claim types which had the highest average
payment per claim were for inpatient hospital stays and long-term
care, which includes nursing facility services and ICF/MR. Figure
I.3 shows the average payment per claim during fiscal years 1993 and
1994. Fiscal year 1995 data are not shown since we could not analyze
a complete year.
Figure I.3: Medicaid Services
With the Highest Cost per Claim
(See figure in printed
edition.)
Source: Unaudited MMIS data.
For fiscal year 1995 (through July 31, 1995), we identified
additional information recorded in MMIS regarding the diagnosis
categories with the highest billed costs for inpatient hospital
services, the largest Medicaid claim type. Table I.3 summarizes this
information.
Table I.3
Diagnosis Categories With the Highest
Billed Costs
Number Total billed
of charges\a
Inpatient hospital diagnosis claims (in millions)
---------------------------- -------- ------------------
HIV 1,043 $14.9
Single live birth 3,844 10.2
Pneumonia 1,057 8.7
Newborn respiratory problems 267 6.2
Single live born--caesarean 1,054 5.2
section
Congestive heart failure 584 5.0
Respiratory failure 87 4.0
Dehydration--alcohol/drug 479 3.5
detoxification
Schizophrenia 523 3.4
Respiratory distress newborn 86 3.1
==========================================================
Total 9,024 $64.2
----------------------------------------------------------
\a Billed charges usually represent amounts greater than the
District's payment to providers for claims processed. Our analysis
showed that approximately 75 percent of total billed charges were
paid to providers by the District.
Source: First Health--Unaudited MMIS data.
Our analysis of the inpatient hospital claims also showed that
treatment for burn-related injures had one of the highest single
costs per claims. For claims paid through July 31, 1995, four claims
submitted by hospitals for burn-related services had billed charges
totaling more than $1.5 million.
Detailed information about the largest cost of health care services
provided to the uninsured was not available because there is no
system like MMIS that captures claims for the uninsured. However,
our work at all District hospitals\2 showed that live births were the
service most often provided by hospitals to uninsured patients. In
addition, uninsured patients with HIV-related conditions, drug and
alcohol treatment, and full-term deliveries with major problems were
some of the most resource-intensive, and therefore the most costly,
services to provide. Also, because St. Elizabeths provides
approximately 77 percent of its care to uninsured persons,
psychiatric care is another costly service.
DEMOGRAPHICS QUESTIONS
--------------------
\2 Although we performed work at all District hospitals, this
analysis was performed on 10 of the hospitals, including St.
Elizabeths. The remaining 5 hospitals could not provide us this
information.
QUESTION ONE
------------------------------------------------------- Appendix I:0.7
What is the current number of Medicaid recipients, the number of
uninsured residents, the number of Medicaid and Medicare enrollees,
and the number of privately insured residents?
GAO RESPONSE
------------------------------------------------------- Appendix I:0.8
We could not obtain exact numbers of uninsured and privately insured
individuals within the District. The District does not maintain
information about its residents' health care insurance status.
However, several organizations have estimated the number of uninsured
persons living in the District.
Table I.4 represents the most current information available on the
number of District Medicaid recipients, Medicaid and Medicare
enrollees, nonelderly uninsured residents, and the number of
privately insured residents accessing services in District hospitals.
The sources of this information are also provided. We could not
substantiate the accuracy of this information.
Table I.4
Insurance Status of District Residents
Most
current Total
fiscal number
year of Source of information (all
Category available persons information is unaudited)
--------------------- --------- -------- -- --------------------------------
Number of Medicaid 1995 124,000 District of Columbia Fiscal Year
recipients 1996 Operating Budget, Volume
II
Number of Medicaid 1994 141,000 Commission on Health Care
enrollees Finance
Number of Medicare 1993 81,320 Department of Health and Human
enrollees Services (HHS)
Number of 1993 100,000 Employee Benefit Research
(nonelderly) to Institute (EBRI)
uninsured residents 125,000
Number of privately 1994 74,515 Hospital data based on number of
insured discharges
--------------------------------------------------------------------------------
QUESTION TWO
------------------------------------------------------- Appendix I:0.9
How many current Medicaid recipients and uninsured residents are
"working poor?"
GAO RESPONSE
------------------------------------------------------ Appendix I:0.10
The number of Medicaid recipients and uninsured residents considered
to be "working poor" was not readily available from any of the
sources we researched. However, based on an average of 100,000
uninsured, the Blue Ribbon Panel\3 estimates that 80,000 are working
poor. We could not confirm the accuracy of this number. Also, we
could not find any information that estimated the number of Medicaid
recipients considered to be working poor.
--------------------
\3 Final Report of the Mayor's Blue Ribbon Panel on Health Care
Reform Implementation, February 1995.
QUESTION THREE
------------------------------------------------------ Appendix I:0.11
How many of the District's children are currently without health care
coverage?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.12
Based on a recent GAO report,\4 it was estimated that in 1993,
23,850, or 16.7 percent, of the District's children were uninsured.
Also according to the same report, in 1993, 64,962, or 45.4 percent,
of the District's children were on Medicaid. We could not readily
obtain more current information.
--------------------
\4 Health Insurance for Children: Many Remain Uninsured Despite
Medicaid Expansion (GAO/HEHS-95-175, July 19, 1995).
QUESTION FOUR
------------------------------------------------------ Appendix I:0.13
What is the District's current physician distribution rate?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.14
The physician distribution rate, according to the Blue Ribbon Panel
Report, is defined as the ratio of physicians that maintain a
practice within a specific location to the specified location's
population. We could not determine the District's physician
distribution rate. However, this report states that the private
physician distribution rate is highest in parts of the city with
moderate and high income populations, such as Wards 1 and 2. Wards 1
and 2 also represent the District's central business area and
contains the three teaching hospitals--Howard University, Georgetown
University, and George Washington University. The ratio of private
practice physicians to population is lowest in areas of the city with
concentrations of the neediest populations, such as Wards 7 and 8.
QUESTION FIVE
------------------------------------------------------ Appendix I:0.15
How many public health clinics are currently in the District, how are
they distributed throughout the District, what are the conditions of
the clinics, and how are they paid for (nonprofit, taxpayer-funded,
etc.)?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.16
The District maintains 11 publicly funded clinics which are
administered by the Commission of Public Health. These clinics are
located in all wards except Wards 3 and 4. The greatest
concentration of clinics is in Ward 2 (three clinics). Wards 5, 6,\5
and 7 each have two clinics. The remaining two clinics are located
in Wards 1 and 8. All DHS clinics have limited hours, operating from
8:15 a.m. to 4:45 p.m., Monday through Friday.
In addition to the 11 public health clinics, there are several
clinics located within D.C. General Hospital. D.C. General is in
Ward 6. These clinics have the same schedule as the DHS clinics, but
services vary depending on the day of the week. For example, on
Mondays the clinics may offer dental services and, on Tuesdays, they
may offer vision services.
We identified 25 private clinics which were mentioned on several
lists as being the District's private health care clinics; therefore,
we included these as the primary private clinics. There may be other
private clinics in the District. Lastly, there are three federally
funded and operated clinics in the District. These clinics are
funded and operated by the U.S. Department of Health and Human
Services.
Table I.5 shows each neighborhood health clinic (NHC) we could
readily identify and its location, except for those clinics located
within D.C. General Hospital.
Table I.5
Clinics Operating in the District and
Ward Location
Federally
funded and
D.C. (DHS) government operated
Ward clinics Private and/or free clinics clinics
------ ---------------------------- ---------------------------------- ---------------
1 Adams Morgan NHC Whitman Walker Upper Cardozo
New Summit Medical Center Health Center
Zacchaeus Free Clinic (adult and
Columbia Road Health Services children)
So Others Might Eat
Mary's Center
Community Medical Center
Spanish Catholic Center
Community of Hope
2 Walker-Jones NHC Health Care for the Homeless None
Claridge Clinic Washington Surgi-Clinic
Southwest NHC Planned Parenthood
Women's Comprehensive Clinic
Center for Ambulatory Surgical,
Inc.
Yater Clinic
3 None Washington Clinic None
4 None The Women's Clinic (Washington None
Hospital Center)
The Washington Free Clinic
La Clinica del Pueblo
Greater Washington Health Center
Hillcrest Women's Surgi-Clinic, NW
5 Woodridge NHC Center for Life (Providence None
Eckington Child Health Hospital)
Clinic
6 15th Street NHC Columbia Hospital Teen Center None
Anacostia NHC
7 Hunt Place NHC Hillcrest Women's Surgi-Clinic, SE East of the
Benning Heights NHC River Health
Center (adults
and children)
Washington
Senior Center
(adults only)
8 Congress Heights NHC S.E. Medical Clinic None
=========================================================================================
Total 11 DHS clinics 25 private clinics 3 federal
clinics
-----------------------------------------------------------------------------------------
Source: District's Commission of Public Health, District of Columbia
Hospital Association (DCHA), Final Report of the Mayor's Blue Ribbon
Panel on Health Care Reform Implementation, February 1995, and
private clinics.
Table I.6 illustrates the type of services offered and the number of
patient visits for each public clinic.
Table I.6
Public Clinics, Services Offered, Ward,
and Number of Patient Visits During 1994
Number of
visits,
Public Clinic Services offered Ward 1994
------------------ ---------------------------------- ------------ ----------
Hunt Place NHC Full service,\a pediatrics, and 7 13,587
pharmacy
Congress Heights Full service, pediatrics, and 8 11,635
NHC pharmacy
Southwest NHC Full service, pediatrics, and 2 10,785
pharmacy
15th Street NHC Full service and pediatrics 6 10,257
Anacostia NHC Full service, pediatrics, and 6 9,800
pharmacy
Benning Heights Full service and pediatrics 7 8,903
NHC
Walker-Jones NHC Full service, pediatrics, and 2 8,356
pharmacy
Woodridge NHC Full service and pediatrics 5 5,309
Eckington Child Pediatrics 5 1,518
Health Clinic
Claridge Clinic Limited services 2 1,177
Adams Morgan NHC Full service 1 1,108
--------------------------------------------------------------------------------
\a Full service clinics offer the following services--adult medicine,
OB/GYN, family planning, and dental.
Source: District's Commission of Public Health.
A recent study\6 of the D.C. public sector health facilities,
performed by the U.S. Public Health Service, Office of Engineering
Services, determined that many of the DHS clinic facilities are
substandard. Examples of substandard conditions range from lack of
accessibility for the disabled to electrical code violations. The
cost to renovate the clinics was estimated at $9 million. In
addition, the cost to renovate clinics located at D.C. General
Hospital was estimated at $849,000. (See appendix IV for a summary
of the results of the study.)
--------------------
\5 Ward 6 now has three clinics, due to the relocation of the
Eckington Child Health Clinic from Ward 5.
\6 U.S. Department of Health and Human Services, Public Health
Service, Deep Look Survey - D.C. Public Sector Health Facilities,
August 1995.
QUESTION SIX
------------------------------------------------------ Appendix I:0.17
What is the current general financial condition of District
hospitals? How many are privately-owned? What is the number of beds
per capita? How many emergency rooms are there and where are they
located? Per capita, are the District's numbers above or below the
national average? Are they above or below those of other local
jurisdictions?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.18
We evaluated the hospitals' financial performance by reviewing
measures of their profitability. Our analysis was based on the
hospitals' fiscal year 1994 financial statements, the most recently
available. For 11 of the 15 District hospitals, operating profit
margins were below the 1993 national average of 3.02 percent (the
most recent year available), with 6 reporting negative operating
margins. The combined operating margin for the 15 hospitals during
their fiscal year 1994 was -$214,583,157 on operating revenues of
$2,067,878,592 or a net loss of 10.4 percent. Table I.7 shows the
hospitals' operating profit margins, which measure the hospitals'
profitability with respect to providing patient care.
Table I.7
District Hospitals' Operating Profit
Margin
Operating profit Operatin
margin as a g Margin
percentage of (in
operating revenue thousand
Hospital (Fiscal year 1994) s)
---------------------------- ------------------ --------
Psychiatric Institute of -172.2 $(9,669)
Washington, D.C.
D.C. General Hospital -116.7 (87,287)
\a
Saint Elizabeths Hospital -110.8 (95,192)
\a
Howard University Hospital -17.5 (34,677)
Children's National Medical -7.2 (15,104)
Center
George Washington University -1.0 (2,077)
Hospital
Washington Hospital Center .5 2,261
Georgetown University 1.1 2,730
Hospital
Greater Southeast Community 1.4 2,827
Hospital
National Rehabilitation 1.6 944
Hospital
Hadley Memorial Hospital 2.2 538
Nationwide average (1993) 3.02 Not
applicab
le
Providence Hospital 3.1 3,627
Columbia Hospital for Women 3.1 2,301
Sibley Memorial Hospital 5.9 6,004
Hospital for Sick Children 20.5 8,190
----------------------------------------------------------
\a In our financial analysis for the District's two public hospitals,
we excluded the $47 million subsidy provided to D.C. General and
$104 million appropriation provided to St. Elizabeths, in fiscal
year 1994, because these amounts are not operating revenue and thus
should not be included when calculating operating margins.
Source: Hospitals' audited 1994 financial statements, except for
George Washington University Hospital, Saint Elizabeths, and the
Psychiatric Institute of Washington, D.C., whose financial statements
were unaudited.
As of June 30, 1995, 15 nonfederal hospitals operated 4,877 beds
within the District of Colombia.\7 Of the 15 hospitals, 2 are
operated by the District of Columbia, 11 are not-for-profit
hospitals, and 1 is a for-profit hospital owned by a partnership.
Eleven of the 15 hospitals, operating 3,558 beds, provide acute care
services (for patients admitted with severe, but not chronic,
conditions), while the remaining 4 operating 1,319 beds provide other
types of inpatient care, primarily long-term psychiatric care.
Table I.8 lists the 15 hospitals, the number of beds they operate,
and their ownership type.
Table I.8
District Hospitals' Capacity and
Ownership (as of June 30, 1995)
Bed
Hospital name capacity Ownership
---------------------------------------- -------- ------------------
Saint Elizabeths Hospital 941 District-owned
Washington Hospital Center 874 Not-for-profit
Greater Southeast Community Hospital 387 Not-for-profit
Howard University Hospital 375 Not-for-profit
Georgetown University Hospital 359 Not-for-profit
Providence Hospital 342 Not-for-profit
George Washington University Hospital 318 Not-for-profit
Sibley Memorial Hospital 275 Not-for-profit
D.C. General Hospital 258 District-owned
Children's National Medical Center 188 Not-for-profit
National Rehabilitation Hospital 160 Not-for-profit
Hospital for Sick Children 119 Not-for-profit
Columbia Hospital for Women 110 Not-for-profit
Psychiatric Institute of Washington, 99 For-profit
D.C.
Hadley Memorial Hospital 72 For-profit
Total bed capacity in D.C. 4,877 Not applicable
----------------------------------------------------------------------
Source: District of Columbia Hospital Association and hospital
financial statements.
Table I.9 shows the location of District hospitals by ward and which
hospitals operated emergency rooms and/or trauma centers as of June
30, 1995.\8
Table I.9
District Hospital Location and Emergency
Room Services Provided
Emergenc Trauma
Ward Hospital y room center
---- -------------------------------------------- -------- --------
1 Howard University Hospital Yes Yes
2 Georgetown University Hospital Yes Yes
George Washington University Hospital Yes Yes
Columbia Hospital for Women No No
3 Sibley Memorial Hospital Yes No
Psychiatric Institute of Washington, D.C. No No
4 Children's National Medical Center Yes Yes
National Rehabilitation Hospital No No
Washington Hospital Center Yes Yes
5 Providence Hospital Yes No
Hospital for Sick Children No No
6 D.C. General Hospital Yes Yes
7 None
8 Saint Elizabeths Hospital No No
Hadley Memorial Hospital Yes No
Greater Southeast Community Hospital Yes No
======================================================================
Tota 15 hospitals: 10 6 trauma
l 2 public emergenc centers
13 private (2 for-profit, 11 not-for- y
profit) rooms
----------------------------------------------------------------------
Source: District of Columbia Hospital Association information.
As shown in table I.9 above, 10 of the 15 hospitals provide emergency
room services, and 6 of the 10 hospitals operate both an emergency
room and a trauma center.
Finally, in 1993, the most recent data available, the District had
the highest acute care bed per captita ratio in the Washington
metropolitan region--7.5 beds per 1,000 person. The regional average
was 2.5 beds per 1,000 person. Figure I.4 shows the number of acute
care beds per 1,000 population for the District and surrounding
jurisdictions in 1993.
Figure I.4: Washington
Metropolitan Region Acute Care
Beds per 1,000 Population-1993
(See figure in printed
edition.)
Source: SACHS Market Planner
and 1992 AHA Guide to
Healthcare.
(See figure in printed
edition.)
--------------------
\7 Two federal hospitals, the Veterans Affairs Medical Center and the
Walter Reed Army Medical Center, also operated 501 and 680 beds,
respectively, in the District as of June 30, 1995.
\8 Trauma centers typically have higher costs to operate than
emergency rooms because they handle patients with life-threatening
injuries, such as gunshot wounds, trauma from automobile accidents,
and heart attacks.
QUESTION SEVEN
------------------------------------------------------ Appendix I:0.19
On what basis are hospitals, public clinics, and emergency rooms
strategically placed? Is a master plan or a patient needs analysis
used to determine their location?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.20
There is no master plan or patient needs analysis for determining the
location of hospitals, clinics, or emergency rooms. According to the
Blue Ribbon Report, the District maintains the same health care
system that existed 30 years ago. Hospital administrators decide the
placement of hospitals, community services offered, and types of
emergency services offered. The Commission of Public Health decides
the placement of community clinics, hours of operation, and services
offered.
QUESTION EIGHT
------------------------------------------------------ Appendix I:0.21
Are there any unique circumstances in the District compared to other
major cities that would result in higher costs for the District to
provide health care?
GAO RESPONSE
------------------------------------------------------ Appendix I:0.22
While we did not identify any circumstances unique to the District,
District hospital officials stated that there were three factors that
contributed to hospitals' operating costs:
-- high salaries for professional staff,
-- high cost of treatment due to complexity of patient cases, and
-- high cost of medical malpractice insurance.
Hospital officials stated that these costs were generally higher in
the District than national averages or in surrounding jurisdictions.
We did not verify this information.
TRENDS IN DISTRICT HEALTH CARE
========================================================== Appendix II
To respond to specific questions you asked (see appendix I for our
responses to those questions), we analyzed information relating to
many aspects of the District's health care system. During our
analyses, we uncovered several issues that we felt were extremely
important to any study of health care in the District. This appendix
discusses those issues in detail.
SUMMARY
First, prior GAO work\1 has shown that more extensive use of managed
care may have the potential to control Medicaid expenditures. Our
work has also indicated that good information on the cost and use of
services plays a critical role in overseeing managed care to realize
cost savings and assure quality of care. Our review of the District
showed that, currently, the city does not collect much of this vital
information or conduct the analyses needed to effectively manage its
programs.
Second, according to hospital officials and a planning study,\2
Saint Elizabeths Hospital and surrounding buildings are in serious
disrepair. The District's Commission on Mental Health Services (also
known as Saint Elizabeths Hospital) spent approximately $142
million,\3 or 11 percent of total District health care expenditures,
in fiscal year 1994. The majority of its expenditures were related
to providing patient care. The most recent renovation information
available is a 1985 estimate of $119 million. Also, hospital
officials state that resources needed to fully maintain the buildings
and systems of the west and east campuses have not been available for
many years. Officials stated and the planning study reported that,
as a result, deterioration of the buildings and system was
accelerated.
Third, our work and studies\4 showed that although the District
government runs both the public hospital and the public clinics, it
does not coordinate medical services, preventive care programs, or
patient information between D.C. General Hospital, the hospital-run
clinics, and the neighborhood clinics. Expenditures at D.C. General
Hospital were $108 million,\5 or 9 percent of total District health
care expenditures, in fiscal year 1994. The District provided D.C.
General $74 million in subsidies, of which $27 million was
characterized as loans, during fiscal year 1994 to offset its
expenditures. In addition, expenditures to operate the District's
public health clinics for this period totaled $21 million. District
officials acknowledge that the failure to integrate its public
facilities contributes to the costliness of delivering public health
care. For example, recipients obtain costly services at a hospital
that could be provided at less cost at a public clinic were the
facilities integrated.
Several external studies\6 concluded that D.C. General Hospital, in
its present state, is not competitive relative to the 13 private
hospitals operating in the District. The studies provide immediate
short-term changes to improve the operations of the hospital and the
services it provides, as well as potentially lowering costs.
Alternatively, because of various factors including the cost to
renovate the hospital, several studies have recommended closing the
facility. Recent estimates to renovate the hospital are $112
million, and estimates to build a new facility are $126 million.
The District provides additional health care services to its
residents through its Commission of Public Health. During fiscal
year 1994, Public Health expended $142 million,\7 or 11 percent of
total District health care expenditures. Public Health administers
numerous programs, the three largest, including Medicaid
expenditures, are (1) the Alcohol and Drug Abuse Administration, (2)
the Ambulatory Health Care Administration,\8 and (3) D.C. Village,\9
the District-run nursing facility.
BACKGROUND
Health care expenditures in the District rose steadily between fiscal
years 1991 and 1994. In fiscal year 1991, expenditures for the four
largest programs--Medicaid, mental health, public health, and D.C.
General Hospital--were $895 million. These same programs accounted
for $1.16 billion in expenditures during fiscal year 1994. This
increase, coupled with limited resources and pending legislative
changes for programs such as Medicaid, have caused the District to
examine options for restructuring its health care system.
The Congress is considering major legislative changes to the Medicaid
program. The changes could include (1) setting a predetermined
ceiling on federal health care funds to each state rather than
unlimited matching federal funds and (2) basing the ceiling on funds
each state is granted on a new formula. The legislative changes
would limit the growth in the District's Medicaid grants to 3.5
percent between fiscal years 1996 and 1997 and 2 percent between
fiscal years 1998 and 1999. Under the current Medicaid program, the
District's Medicaid grants increased 15 percent between fiscal years
1993 and 1994.
Public Health's two primary roles are to provide education and
prevention programs and ensure adequate access to health care for all
District residents. Many of Public Health's programs are supported
by the Medicaid program or are intended to support D.C. General's
mission. Therefore, we focused on Public Health as it relates to
these two roles. We do not discuss Public Health separately, but
rather the need for basic information from the Medicaid program to
make management decisions about the placement and types of education
and prevention programs in our Medicaid discussion. Also, our work
at the 11 neighborhood clinics is discussed along with that on D.C.
General and the lack of integration between the clinics and the
hospital.
Numerous studies have been performed to identify problems with the
District's health care system and to suggest solutions.
Recommendations from some of these reports are summarized in appendix
III.
MEDICAID PROGRAM LACKS ESSENTIAL
COST INFORMATION
Health care providers submit claims for eligible services provided to
District Medicaid recipients to First Health, a District contractor.
First Health processes the claims through the Medicaid Management
Information System (MMIS) to determine the amounts to be paid for
each claim. MMIS either approves or denies the claims based on
various parameters within the system, such as an approved provider or
Medicaid recipient number. Denied claims are sent back to the
providers. The District sends approved payments directly to the
providers and draws down the related federal share payment from its
annual federal matching Medicaid grant.
Reimbursements to hospital, long-term care,\10 and Health Maintenance
Organization (HMO) providers comprised more than 75 percent of
Medicaid expenditures in 1994. However, the program's information
system either does not collect sufficient cost and service data for
these providers or the District does not utilize available
information to determine if funds are being spent most effectively.
Providers are reimbursed costs based on (1) cost reports which detail
total operating costs of hospitals and long-term care facilities and
which are audited often 2 years after the providers' operating
year-end and (2) pre-established rates for HMO providers.
The District attempted to determine the HMO provider rates by using
the full cost of Medicaid services for the Aid to Families With
Dependent Children (AFDC) population, discounted by 7.5 percent.
However, data needed to perform this calculation was not readily
available in the District's information system. As a result, the
pre-established rates for reimbursing HMOs do not reflect the true
cost to provide these services and may be excessive. In addition,
the District does not capture data necessary to ensure that those
rates are competitive. Until the District is able to determine its
providers' actual costs for delivering each type of health care
service, it will not be able to determine reasonable reimbursement
rates to effectively control costs, nor will it be able to recognize
unreasonable reimbursement requests.
The MMIS system collects information on all Medicaid claims and
groups them in 13 claim types, the largest of which were inpatient
hospital, long-term care, and outpatient care for fiscal year 1994.
Our analysis of MMIS showed the following.
-- The District does not routinely reconcile detailed amounts in
the MMIS database to its accounting records--Financial
Management System (FMS)--which records payments made to
providers for Medicaid claims. Although District officials
attempted to reconcile 1994 amounts in response to our review,
they could not explain an $11 million difference between MMIS
data ($779 million) and FMS data ($768 million).
-- Detailed information about the type of services provided and the
cost of those services is not maintained for many of the claim
types in the MMIS system. For example, an analysis of the HMO
claims data--the largest category of claims reimbursed on a
pre-determined, negotiated rate (known as the capitation rate)--
revealed that the type of services provided by a practitioner,
such as prenatal care versus well-baby visits, and the itemized
costs of providing each type of service are not captured in the
system. Instead, all services provided under HMO claims were
described as "other." District officials state that it does
collect information on the service utilization of HMO members,
but the information is in aggregate form, and is not
comprehensive enough to allow for any kind of systematic
financial or programmatic analysis. According to District
officials, the Commission on Health Care Finance is now in the
process of expanding these reporting requirements to address
these shortcomings.
-- Hospital claims data--the largest category of claims
paid--contained information about the type of services provided
and billed charges; however, no analysis is conducted to compare
costs of treating the same condition across hospitals to
determine which hospitals are least expensive.
-- MMIS inpatient hospital claims data for 52,577 claims totaling
$347 million did record diagnosis; however, payment data was not
recorded for each claim.
Lack of descriptive information about specific services provided and
cost hampers the District's ability to (1) compare and contrast the
cost-effectiveness of providers, (2) determine the reasonableness of
cost reimbursements, (3) assess the appropriate levels of patient
care, (4) forecast future health trends, and (5) determine what
education and prevention programs should be provided.
To illustrate, it would be useful for the District to know what
services a patient participating in an HMO received and their costs.
This basic information would allow the District to compare providers
delivering a similar service and determine who was providing care at
the least cost. This would subsequently enable the District to more
effectively evaluate the cost-effectiveness of HMOs and use this
information as a tool for evaluating proposed capitation rates and
selecting HMOs to participate in its managed care program. This
information could also be used by the District in performing quality
reviews of providers to assess whether the appropriate levels of care
are being administered.
Our work also revealed instances where the information that is
collected was not useful.
-- The District does not collect cost information about optional
Medicaid services in a manner that is useful for cost
containment. Each state may elect to provide an additional 34
services\11 above those services required under federal
regulations. District officials estimate that these optional
services, such as physical therapy and hospice care, cost
approximately $180 million, or 23 percent, of total Medicaid
spending. However, we could not substantiate this figure
because of the way costs were grouped in the MMIS database.
While some optional services are easily identified, such as
dental services, others are not. For example,
Under federal government regulations, "eyeglasses" are an optional
service states can choose to provide. Although the District provides
this service, the claims data we analyzed did not use "eyeglasses" to
define services under this claim type, but rather categorized all
vision related claims under the broad category "vision." Therefore,
the District cannot determine how much it spends on providing
eyeglasses to its Medicaid population.
Similarly, "physical therapy," another option provided by the
District, is not a recognized service in the database and, thus, the
District cannot determine how much it spends to provide this service.
In instances where the District has collected necessary information,
it did not always use the information to adequately oversee the
program. For instance, our analysis of the MMIS database showed that
7 percent of total claim payments, or $29 million, processed in 1994
was for recipients with zip codes outside the District. Since MMIS
did not include payments of approximately $342 million for inpatient
hospital claims, this amount is probably understated. District
officials stated that these claims were for individuals who lived
outside of the city but were still wards of the state, such as
children in foster care and individuals in nursing homes. However,
the District does not investigate any of these cases and continues to
pay claims as long as individuals have a valid Medicaid recipient
number. Thus, an individual may move out of the city and continue to
receive the District's Medicaid benefits for an undetermined period.
Given the District's resources and rising health care costs, this
type of information is important to the District. Obtaining
information on the cost of providing specific optional services will
be critical to the District not only in making informed decisions
about what services should be continued or eliminated, but also in
quantifying potential cost-savings. The District could also make
better use of the information it collects to monitor the Medicaid
program.
Our work also revealed anomalies in the MMIS database that District
officials could not explain. These are discussed in detail in
appendix V. For instance, long-term care claim types contained (1)
claims where the gender codes were categorized as unknown and (2)
claims that had negative amounts paid. Although the District has a
system to capture demographics on those eligible for Medicaid, the
MMIS is not designed to routinely report demographics on Medicaid
recipients. Thus, the District does not have an accurate demographic
profile of its Medicaid recipients nor does it know the financial
impact of the negative amounts paid.
FACILITIES AT SAINT ELIZABETHS
HOSPITAL NOT BEING ADEQUATELY
MAINTAINED
The Commission on Mental Health Services (CMHS) administers the
District's mental health system within DHS. Inpatient and some
outpatient services are provided at Saint Elizabeths Hospital. The
District houses inpatients on the east campus and uses a portion of
the west campus for administrative purposes and some patient care.
As a result of actions taken under the Saint Elizabeths Hospital and
District of Columbia Mental Health Services Act, the District
currently owns most of the east campus and the federal government
owns most of the west campus.\12 The Secretary of the Interior
designated Saint Elizabeths Hospital a national historic landmark in
1990.
The federal government's portions of the west campus are vacant. The
District pays for the maintenance and upkeep of the entire west
campus but is not reimbursed by any other source. Costs to annually
maintain the west campus were estimated at $6 million in 1993.\13
Hospital officials estimated costs to maintain vacant, federally
owned buildings at approximately $1 million per year through fiscal
year 1991. According to hospital officials, some of the west campus
is necessary for the operation of the east campus since (1) the
current configuration of the east campus could not provide all
patient services without substantial improvements, including
significant asbestos removal, and (2) the boiler plant, which is the
main source of heat for the east campus, is located on the west
campus; however, the boiler is in serious disrepair.
Section 4(f)(1) of the act required the Secretary of Health and Human
Services (HHS) to contract for a physical plant audit of the existing
facilities at Saint Elizabeths Hospital to assist the Mayor in
developing a comprehensive mental health system plan. The physical
plant audit was required to recognize any relevant national and
District codes and estimate the useful life of existing facility
support systems. Section 4(f)(2) provided that, after the audits,
the Secretary was to initiate and complete repairs and renovations of
the physical plant and facility support systems--as necessary to meet
any applicable code requirements or standards--of Saint Elizabeths
Hospital that were to be used by the District of Columbia under the
comprehensive mental health system plan. In 1991, section 4(f)(2)
was amended to authorize the Secretary to provide the Mayor with
funds to complete such repairs and renovations.
In 1985, the U.S. Department of Health and Human Services conducted
the required physical plant audit of all existing facilities of Saint
Elizabeths Hospital. At the time, the estimated cost to bring the
physical plant and facility support system into compliance with
applicable laws and codes was $56.5 million. This audit assumed that
the District would temporarily use the west campus for its
operations, but that eventually all hospital operations would be
consolidated on the east campus. The District has filed a complaint
in the United States Court of Federal Claims seeking recovery of
amounts the District alleges the United States owes it under various
provisions of the act. The complaint alleges that the United States
neither made nor provided the District all the funds necessary to
make the repairs and renovations indicated by the 1985 audit. The
complaint seeks about $60 million based on the difference between the
estimated cost of the repairs and the amount the United States
previously provided the District, as adjusted for inflation.
The District also hired a contractor to estimate the additional costs
to renovate the facility for patient use. These costs were estimated
at $62 million. The additional costs were not necessary to comply
with the requirements of the transfer. Even if the District prevails
in its suit and recovers the amount claimed, it is unclear how the
District intends to fund the remaining repairs and renovations to
Saint Elizabeths identified by the District's audit. In addition, it
is unclear how much the historic landmark designation has affected
the 1985 audit's cost projections for repairs and renovations.
However, it is not unreasonable to assume that they will increase as
a result of the designation.
Section 8(b) of the act required the Mayor to submit to the Congress
for approval a master plan for the use of the remaining untransferred
property at Saint Elizabeths. The plan was submitted to the Congress
in December 1993.\14 Section 8(b) provides that if a law is enacted
approving the plan, the Secretary is required to transfer the
property to the District in accordance with the approved plan without
compensation. The plan submitted to the Congress called for
renovating and restoring the west campus for institutional, retail,
and support-type facilities, using the guidelines for historical
properties. However, the planners noted that the market for such
users at this location was weak. During the process of developing
the master plan, three alternatives consistent with the historic
landmark designation were examined. Their costs ranged from $116
million to $128 million. No other comparable use plan was prepared.
The plan also recommended that the transfer of the west campus not
proceed until the mutual interests of the federal and district
governments were reconciled since, according to the planners, the
District "does not have the resources to undertake adaptive reuse of
the west campus and that current transfer would adversely impact both
the historic resource and its potential contribution to the national
and local economies." Also, it states that the Commission on Mental
Health's budget to fully maintain the buildings and systems of the
west and east campuses has been severely underfunded for so long that
the "inevitable deterioration of the buildings and system has been
accelerated," and the District must address the most critical
conditions on a crisis management basis.
According to District officials, the majority of its fiscal year 1994
mental health expenditures were for patient care. We did not perform
an audit or efficiency study of these costs, but hospital officials
estimate that patient costs will remain relatively constant over the
next few years. Since most of the budgeted mental health funds are
used for patient care, such as physician and staff salaries and
contracts for outpatient community housing, hospital officials stated
that they have not been able to dedicate substantial funds for
facilities improvement. Currently, the District is in the process of
studying its mental health care system to identify ways to reduce
costs and improve efficiency.
OPERATIONS OF PUBLIC HEALTH CARE
ARE INEFFICIENT AND FACILITIES ARE
DETERIORATING
Operating expenses for D.C. General Hospital were $141 million in
fiscal year 1994. Several studies\15 on the hospital, including our
comparison of fiscal year 1994 operating results (see table I.7 in
appendix I) show that, in its present state, D.C. General is not
competitive relative to the 13 private hospitals operating in the
District. The studies provide immediate short-term changes which
could improve the operations of the hospital and the services it
provides, as well as potentially lower costs.
The number of patients served at D.C. General has decreased, and the
physical condition of its 53-year old facility has deteriorated.
Some of the decrease in patients served is attributed to the shift of
Medicaid recipients by the District to managed care organizations
such as HMOs and the hospital's poor physical condition. In
addition, none of the four HMOs serving the Medicaid AFDC population
are associated with D.C. General and thus would not routinely send
their members there for treatment.
The District's 11 public clinics are not integrated with D.C.
General. The clinics and D.C. General Hospital do not (1) share
patient data, (2) maintain a referral network, or (3) coordinate
patient care and programs. This lack of coordination
-- allows recipients to obtain services at the public hospital
which, according to District officials, could be provided for
less at a public clinic;
-- prevents the District from adopting a strategic outlook to
delivering public health care;
-- forces the public facilities to compete for resources which
would possibly be better shared; and
-- may cause duplicative and unnecessary services to be provided to
citizens.
For instance, during our visit to D.C. General, we observed patients
who used the walk-in emergency room services to refill a prescription
or obtain treatment for a headache. One asthmatic patient received
treatment for a condition which, according to hospital officials,
could have been more appropriately treated by the patient's primary
care physician. Because patient records were not available at the
hospital, hospital staff had to run routine tests before treating the
patient. This information would have been readily available if the
patient had gone to his or her primary care physician. Also, during
our visit, hospital officials stated, and we observed, that patients
had gone to the emergency room and lab work had been performed, but
that the patients left before the results were known. Hospital
officials stated that often these individuals return to the emergency
room another day and the tests are done again. In some cases, a
patient's condition worsens between visits and the patient has to be
hospitalized.
During fiscal year 1995, the Office of Engineering Services in the
U.S. Department of Health and Human Services conducted a survey\16
of the hospital and concluded that it was in such disrepair that it
would exceed $112 million to renovate or $126 million to build a new
facility. The $112 million cost to renovate does not include an
additional $849,000 which the same study estimates is the cost to
repair the public clinics located within the hospital. The report
cited serious deficiencies including poor heating, ventilation, and
air conditioning; asbestos; unsanitary conditions in the obstetrics
and gynecology department; inoperative laundry equipment; and
inadequate ventilation in the surgical pathology lab.
In addition, the same survey identified numerous deficiencies at
seven of the public clinics. Estimates to repair the deficiencies
exceed $9 million. The deficiencies include poor heating,
ventilation, and air conditioning; filthy and clogged filters; no
emergency power or fire alarm system; and overcrowding. Appendix IV
summarizes the results of this study.
These same studies (see footnotes 15 and 16) also reported that (1)
the hospital facilities are in major disrepair--estimates to repair
or renovate the facility exceed $112 million, (2) hospital operations
are inefficient and noncompetitive with the private sector, and (3)
the quality of health care could be improved. In addition, D.C.
General reported nearly $78 million of uncompensated care during
fiscal year 1994. From fiscal year 1991 through 1994, the District
provided a total of $309 million in subsidies, of which $75 million
was characterized as loans, to cover large operating deficits.
Detailed recommendations for solving problems at D.C. General and
the public clinics have been provided to the District. These
recommendations, which range from closing the hospital to integrating
the clinics with the hospital, are summarized in appendix III.
--------------------
\1 Arizona Medicaid: Competition Among Managed Care Plans Lowers
Program Costs (GAO/HEHS-96-2, October 4, 1995).
\2 A Master Plan for the West Campus of Saint Elizabeths Hospital;
Devouax and Purnell Architects - Planners, P.C., September 1993.
\3 Total operating expenses for Saint Elizabeths were $207 million
for fiscal year 1994. This includes $65 million of Medicaid
expenses, as well as depreciation and accruals.
\4 Final Report of the Mayor's Blue Ribbon Panel on Health Care
Reform Implementation, February 1995 and District of Columbia Health
Sector Analysis Final Report, Lewin-VHI, Inc., December 5, 1995.
\5 Total operating expenses for D.C. General were $141 million for
fiscal year 1994. This includes $33 million of Medicaid expenses.
\6 District of Columbia General Hospital--Operational and Financial
Viability Plan, dated May 1994, and U.S. Department of Health and
Human Services, Public Health Service, Deep Look Survey - D.C.
Public Sector Health Facilities, August 1995. The Deep Look Survey
was a series of in-depth studies of the physical condition of D.C.
General and several public clinics.
\7 Total operating expenses for the Commission of Public Health were
$181 million for fiscal year 1994. This includes $38 million in
Medicaid expenditures.
\8 The Ambulatory Health Care Administration is responsible for the
District's 11 neighborhood health clinics.
\9 We did not perform detailed work at D.C. Village because the
District plans to close the facility in April 1996. According to
District officials, they are experiencing difficulty in placing
residents in other nursing homes and did not believe they would be
able to meet the April 1 deadline.
\10 Long-term care includes nursing facilities services and
intermediate care facilities for the mentally retarded.
\11 According to the U.S. Health Care Financing Administration, the
District elected to provide 26 of the 34 optional services;
nationwide, the average was 24.
\12 The Saint Elizabeths Hospital and District of Columbia Mental
Health Services Act, Public Law
No. 98-621 (1984), authorized the Secretary of Health and Human
Services to transfer to the District of Columbia all property at
Saint Elizabeths Hospital needed by the District's Department of
Human Services to provide mental health and other services under the
District's comprehensive mental health system plan. On September 30,
1987, the Secretary transferred title to almost all of the portion of
Saint Elizabeths that is commonly referred to as the east campus and
several buildings on the portion of Saint Elizabeths that is commonly
referred to as the west campus for these purposes.
\13 A Master Plan for the West Campus of Saint Elizabeths Hospital;
Devouax and Purnell Architects - Planners, P.C., September 1993.
\14 A Master Plan for the West Campus of Saint Elizabeths Hospital;
Devouax and Purnell Architects - Planners, P.C., September 1993.
\15 Four Years Later--The Rivlin Report Revisited: An Assessment of
Progress in the District of Columbia, Final Report, December 1994,
and District of Columbia General Hospital--Operational and Financial
Viability Plan, May 1994.
\16 U.S. Department of Health and Human Services, Public Health
Service, Deep Look Survey - D.C. Public Sector Health Facilities,
August 1995.
STATUS OF RECOMMENDATIONS
========================================================= Appendix III
Over the past several years, various comprehensive studies have been
conducted on the District's health care system. We reviewed four of
these studies and categorized the resulting recommendations into
"fully implemented," "partially implemented," and "not implemented,"
based on our analysis. Many of the recommendations relate to the
establishment of a Public Benefit Corporation (PBC). This
corporation would restructure the District's health care system to
separate the health delivery functions from public health policy and
regulatory functions. According to District officials, the
establishment of this corporation is still in the planning stages,
with partial implementation anticipated by April 1996 and completion
by September 30, 1996. We view initiatives that are still in the
development or planning stages as ongoing, but continue to categorize
them as "not implemented."
Additionally, the status of these recommendations reflects the
representations of District officials. We did not confirm the status
of implementation nor did we evaluate the effectiveness of the
District's actions to implement the recommendations. The four
studies we reviewed are
-- Four Years Later: Rivlin Report Revisited, December 1994 (RII);
-- Final Report of the Mayor's Task Force on Long-Term Strategies
to Improve the District of Columbia's Public Health Care
Delivery System, January 1994 (LTS);
-- Final Report of the Mayor's Blue Ribbon Panel on Health Care
Implementation, February 1995 (BR); and
-- District of Columbia General Hospital - Operational and
Financial Viability Plan, May 1994 (K).
Not
Fully Partially implemente
Issue Recommendation implemented implemented d
-------------- -------------------- -------------- -------------- ----------
Public health (1) Create a new X
care delivery Public Benefit Plan for
system Corporation to partial
separate the health implementa
delivery functions tion by 4/
from public health 1/96,
policy and completion
regulatory by 9/30/
functions. (RII, BR, 96.
LTS)
(2) Reconstitute the X
current Commission Anticipated
of Public Health to completion
a cabinet-level 9/30/96.
Department of
Health. (BR, LTS)
(3) Restructure D.C. X
General (and Saint Part of
Elizabeths-RII) PBC.
under the new Public Partial
Benefit Corporation, implementa
with D.C. General to tion by 4/
serve as an acute 1/96,
care facility. (BR) completion
by 9/30/
96.
(4) Effectively use X
health professionals Ongoing.
such as nurse
practitioners, nurse
midwives, and
physician
assistants. (BR)
(5) Involve health X
professionals in any Effective 10/
government- 95.
organized group or
initiative seeking
ways to improve the
delivery of health
care in the
District. (LTS)
(6) Develop an X
organized system to Developing
collect, analyze, new system
and report health in
statistics and coordinati
information; on with
establish mechanisms the
for data uniformity federal
and linkage; and government
provide valid and .
timely data capable
of supporting
program and
management decisions
and forecasting
future health
trends. (LTS)
(7) Create an X
oversight board with Advisory Board
representatives of for D.C. Gen.
the city and Legis. to
community to set explore
policy for the establishment
hospitals and the of PBC board.
clinics. (RII)
(8) Create a X
private, not-for- Ongoing.
profit, self- Anticipate
sustaining d
corporation working completion
in cooperation with 9/30/96.
the new D.C.
Department of Public
Health to create and
administer health
research projects.
(LTS)
(9) Establish an X
office or bureau Reestablished
within the 1/96.
Department of Public
Health to collect
and disseminate
health statistics in
the District
uniformly. (LTS)
(10) Direct the X
Department of Public Anticipated
Health to work with completion 9/
public and private 30/96.
hospitals and other
providers to develop
a comprehensive
approach to ensure
access for all
residents to acute
care services. (LTS)
(11) Support the X
operation of the
D.C. General
Hospital
Association. (LTS)
(12) Establish a X
formal relationship
between the
Department of
Corrections Health
Services and the new
Department of Public
Health. (LTS)
(13) Determine X
whether to transfer Final
the Emergency determinat
Medical Service ion being
(EMS) Bureau of the made.
D.C. Fire Department Discussion
(DCFD) to the new s concern
Department of Public privatizin
Health, or whether g
it should remain as ambulance
a separate bureau services.
within the
DCFD.(LTS)
(14) Evaluate the X
current EMS response New dispatch
system to determine system in
what improvements, place.
if any, should be Additional
made to the dispatch evaluation
system and how EMS ongoing.
responds to calls
for assistance.
(LTS)
(15) Direct EMS and X
the Department of Centralize
Public Health to d trauma
develop a patient registry
monitoring system to to be
follow up and refer establishe
patients seen by EMS d in FY
staff for post- 1996.
emergency treatment.
(LTS)
Primary care (1) Develop a system X
of primary care by Ongoing.
redirecting a
significant amount
of public health
resources from acute
and chronic care to
preventive health
services. (BR, LTS)
(2) Replace the X
current 11 public
clinics with a
reduced number of
regional primary
care centers. (RII,
BR)
(3) Integrate the X
District's public Currently
clinics, including integrating
their information clinics with
systems, into the D.C. General
operation of various
hospitals, with a
view towards
improving referral
relationships
between the clinics
and District
hospitals. (K, LTS)
(4) Establish a X
central authority Part of
responsible for PBC.
coordinating primary Partial
health care services implementa
provided by the tion by 4/
public sector to the 1/96,
District's most completion
vulnerable by 9/30/
populations. (BR) 96.
(5) Identify the X
public sector Ongoing.
resources that will Anticipate
be required to d
deliver necessary completion
health services in 9/30/96.
an economical and
effective manner to
the citizens of the
District of
Columbia. (LTS)
(6) Increase the X
cultural sensitivity Ongoing.
and bilingual
resource capability
of employees
throughout the
public health care
system, and promote
primary health care
education throughout
the community,
including the
Spanish-speaking
population. (LTS)
(7) Increase access X
to primary and Ongoing.
preventive care
through incentives
directed at the
private health care
sector. (LTS)
(8) Support national X
efforts to increase Primary care
the number of cooperative
primary care agreement and
practitioners by grants being
offering incentives implemented.
to medical and
dental students and
health care
providers to enter
into primary care.
(LTS)
(9) Support training X
for individuals from
different cultural
backgrounds to be
health care
providers. (LTS)
(10) Support X
continued
cooperation between
the Commission of
Public Health and
the D.C. Public
Schools to provide
health services in
D.C. public schools
and support for
public health
programs for
students. (LTS)
(11) Direct the X
Department of Public Ongoing.
Health to work with
the D.C. Public
Schools to develop
programs to promote
the mental and
physical well-being
and environmental
needs of school-
aged children in
order to promote
good health into
adulthood. (LTS)
(12) Support X
continued training Ongoing.
for careers in
health services by
the D.C. Public
Schools and the
University of the
District of
Columbia. (LTS)
Long-term care (1) Provide a X
unified case
management system
for continuity of
care and appropriate
level of care for
persons being
treated in public
and private long-
term facilities.
(LTS)
(2) Evaluate the X
need for the
District government
to continue to
operate long-term
care facilities in
light of current and
projected future
incentives for
private sector
initiatives in this
area. (LTS)
D.C. General (1) Contract with X
Hospital the new Public Completion
Benefits Corporation anticipated 9/
(PBC) for prison 30/96.
care and specify
levels of care for
the medically
indigent population.
(K)
(2) Replace the core X
building of D.C.
General, purchase
and remodel an
existing hospital
for D.C. General, or
close D.C. General
and distribute
patients to area
hospitals. (RII)
(3) Establish a X
Facility Practice Tentative
Plan for physicians frame work
currently employed developed.
at D.C. General and
the public clinics.
(K)
(4) Integrate the X
public clinics with Part of
D.C. General PBC.
Hospital to improve Partial
the quality and implementa
cost-effectiveness tion by 4/
of care provided 1/96,
through the sharing completion
of operational by 9/30/
resources and 96.
management systems.
(K)
(5) Identify a X
financial team to
target a reduction
in net accounts
receivable from 119
days to 75 days. (K)
(6) Implement all X
nonlabor expense
reduction
recommendations. (K)
(7) Reorganize the X
administrative Part of
support functions PBC.
and Partial
responsibilities. implementa
(K) tion by 4/
1/96,
completion
by 9/30/
96.
(8) Put the goals X
and objectives of Part of
the Leadership/ PBC.
Management section
of the hospital
strategic plan into
operation. (K)
(9) Transfer X
hospital employees Part of
to the PBC and allow PBC.
the corporation to
establish a
personnel system,
including
recruitment and
retention policies
and wage and salary
administration. (K)
(10) Track and X
monitor length of
stay information by
DRG. (K)
(11) Implement a DRG X
optimization program Evaluation
and apply for a underway.
"fee-for-service"
provider designation
to allow the
hospital to function
as a managed care
provider. (K)
(12) Reduce linen X
usage through
internal controls
and education. (K)
(13) Implement X
inventory reduction
and control
recommendations. (K)
(14) Enforce and X
monitor the policy
requiring proof of
D.C. residency as a
prerequisite for
registration for
nonemergency care.
(K)
(15) Consolidate the X
inpatient pharmacy
and implement a co-
payment policy for
the outpatient
pharmacy. (K)
(16) Develop a plan X
to reconfigure
outpatient pharmacy
services, similar to
other public
hospitals. (K)
(17) Consolidate the X
administrative
support structure
for the Georgetown
and Howard
Ambulatory Care
Clinics into one
outpatient center.
(K)
(18) Integrate the X
Emergency Services Completion
(ECC, Psychiatry anticipated 7/
Emergency, and 31/96.
Pediatric Emergency)
into one Emergency
Care Center. (K)
(19) Undertake a X
systematic review of
all programs,
clinical and
academic, to assess
the relative
contribution of each
program to the
hospital's mission
and the specific
role of each in the
hospital's future.
(K)
(20) Reduce X
workforce to levels
consistent with
industry norms. (K)
Saint (1) Develop a X
Elizabeths community mental
health care system.
(RII)
(2) Reallocate staff X
to direct patient
care. (RII)
(3) Hire additional X
physicians. (RII) Currently
underway.
(1) Establish an X
Independent independent
commission commission to
further develop and
implement the reform
initiatives
recommended in the
Blue Ribbon report.
(BR)
Regulatory (1) Adopt tort X
reform reform measures with
provisions which are
comparable to those
of Maryland and
Virginia, including
those relating to
caps on noneconomic
loss, attorney fees,
collateral source,
periodic payments,
statute of
limitations, and
certificate of
merit. (BR)
(2) Enact insurance X
reform in the small
employer market.
(BR)
(3) Designate the X
new D.C. Department Part of
of Public Health as PBC.
the State Health Partial
Authority for the implementa
District of Columbia tion by 4/
with the 1/96,
responsibility to completion
implement and by 9/30/
coordinate the 96.
District's Health
Care Reform
Initiative, which
includes
establishing health
alliances,
certifying health
plans, monitoring
quality/
availability of
health care, and
implementing
insurance reform.
(LTS)
(4) Transfer X
licensing authority Part of
for health care PBC.
providers in the Partial
District of Columbia implementa
from the Department tion by 4/
of Regulatory 1/96,
Affairs to the new completion
Department of Public by 9/30/
Health. (LTS) 96.
(5) Transfer the X
licensing of Part of
hospitals and health PBC.
facilities to the Partial
new Department of implementa
Public Health. (LTS) tion by 4/
1/96,
completion
by 9/30/
96.
Managed care (1) Develop a X X
managed care Half of Aid to Full
program--could Families With implementa
include the Dependent tion by 8/
Supplemental Children (AFDC 96.
Security Income and AFDC-
(SSI) Medicaid related)
eligible and, enrolled in
possibly, the HMO.
indigent. (RII)
(2) Vigorously X
explore use of a Full
Medicaid waiver to implementa
develop models such tion by 9/
as those which are 30/96.
being implemented in
other states,
designed to better
use resources. (BR)
Financing/ (1) Expand use of X
expenditures Medicaid Implemented in
reimbursement for 1992.
residential care
facilities for
delinquent youth in
out-of-state
facilities (for
mental health) and
to create prenatal
care package to be
financed by
Medicaid. (RII)
(2) Seek an increase X
in the inpatient and
outpatient Medicaid
reimbursement rates
by enactment of the
State Health Plan
Amendment. (K)
(3) Initiate on- X
site Medicaid
enrollment at the
time of admission or
initial encounter at
D.C. General. (K)
(4) Consider doing a X
feasibility study on
establishing a
hospital cost review
and cost setting
commission for
District hospitals
to control cost and
capacity, as well as
a mechanism for the
equitable
distribution of
uncompensated care
among District
hospitals. (BR)
(5) The District X
should vigorously Ongoing.
pursue an improved
Medicaid match. (BR)
(6) Facilitate the X
Medicaid enrollment Ongoing.
process, especially
for those with
language and/or
social impediments.
(BR)
(7) Establish a X
mechanism to review Proposed
the Medicaid benefit cuts
package and identify planned in
opportunities to FY 1997.
reduce optional
benefits. (BR)
(8) Create an X
indigent care trust
fund to spread costs
to subsidize health
care costs for the
uninsured. (RII)
(9) Reduce District X
health expenditures Planning
in the range of $80 to cut
to $100 million approximat
(from fiscal year ely $80
1994 base) to bring million in
District FY 1997.
expenditures closer
in line with other
jurisdictions. (BR)
--------------------------------------------------------------------------------
DEEP LOOK SURVEY COSTS TO FIX OR
REPLACE DISTRICT HEALTH CARE
FACILITIES
========================================================== Appendix IV
During fiscal year 1995, the Office of Engineering Services in the
U.S. Department of Health and Human Services conducted a survey of
D.C. General Hospital, its surrounding clinics, and seven of the
District's public clinics. The surveys consisted of site visits,
in-depth inspection of the facilities, and follow-up recommendations.
Each recommendation includes a cost estimate to fix noted
deficiencies. However, since the inspections were limited,
additional costs could accrue.
Public Size
health Total costs to (sq.
facility fix/repair Age ft.) Description of problems
------------ -------------- -------- -------- -- -------------------------------------
D.C. General
and
Surrounding
Clinics
D.C. General $112,266,586\a Ranges 1,039,07 (1) Poor roofs and floors;
Hospital from 6 (2) Evidence of asbestos;
1927 to (3) Poor heating, ventilation, and
1979 air conditioning (HVAC);
(4) Poor maintenance of hospital and
Average evidence of
53 years vandalism;
(5) Patient toilets deteriorating and
not well
maintained;
(6) Hazardous material and specimens
not
stored in locked areas;
(7) Laundry equipment not properly
working;
(8) Exterior clinic wall crumbling;
(9) Severe sanitation problems in OB/
GYN;
(10) Elevator out of service;
(11) Handicap ramp in disrepair;
(12) Flooded mechanical room and
inoperative
emergency generator;
(13) Ventilation in surgical
pathology lab inadequate
and a health hazard;
(14) Ceiling problems; and
(15) Violation of life safety codes
in Archibold Hall.
Sexually $144,701 Built in 9,824 (1) Severely overcrowded\b;
Transmitted (renovate) 1943 and (2) Hazardous conditions in pipe
Disease renovate crawl space;
(STD) Clinic $50,000 d in (3) Education center not operating
at D.C. (annual 1987 due to lack of
General maintenance funds;
Hospital contract) Was (4) Faulty windows and water damaged
intended ceiling;
to be (5) Roof damaged;
temporar (6) HVAC upgrades needed; and
y (7) Lack of routine maintenance and
shortage of hot
water.
Tuberculosis $224,705 Built in 10,560 (1) Preventive maintenance
(TB) Clinic (renovate) 1943 and necessary;
at D.C. renovate (2) Fire door holders needed;
General $50,000 d in (3) Air flow inadequate--poor
Hospital (annual 1987 ventilation;
maintenance (4) HVAC system energy efficient, but
contract) Was not the
intended preferred design for reducing risk of
to be TB
temporar transmission;
y (5) Portable air filters not
effective; and
(6) TB infection control guidelines
not met.
Karrick Hall $269,237 Built in Not (1) Patient rooms need refurbishing;
at D.C. (renovate) 1964 stated (2) Asbestos abatement needed for
General pipe insulation
Hospital $75,000 Was removal;
(annual intended (3) Electrical work needed;
maintenance to be (4) Smoke detectors not spaced
contract) temporar correctly;
y (5) Handicap access problems;
(6) HVAC repairs needed;
(7) Plumbing fixtures need
replacement;
(8) Laundry equipment not fully
operational;
(9) One or two elevators broken; and
(10) Routine preventative maintenance
needed.
Detox Center $83,487 Built in Not (1) Bathrooms need refurbishing;
at D.C. (renovate) 1943 and stated (2) Repair of walls and replacement
General renovate of windows
Hospital $60,000 d in needed;
(annual 1987 (3) Repair of rear security door
maintenance needed;
contract) Was (4) Handicap access problems;
intended (5) Repair of air conditioning system
to be needed;
temporar (6) Additional water fountains
y needed;
(7) Replacement of ceiling tiles
needed; and
(8) Preventive maintenance needed.
TRAIN II $64,948 Built in 14,400 (1) Preventive maintenance needed;
Clinic at (renovate) 1943 and (2) Repair of windows needed;
D.C. General renovate (3) Replacement of door frames and
Hospital $50,000 d in hardware
(annual 1987 needed;
maintenance (4) Air flow inadequate--poor
contract) Was ventilation;
intended (5) Replacement of ceiling tile
to be needed;
temporar (6) Removal of debris from roof and
y drains needed;
(7) Handicap access problems; and
(8) Poor ventilation and air flow--
heat and humidity
cause pneumatic controls to
malfunction.
Women's $62,265 Built in 11,000 (1) Preventive maintenance needed;
Services (renovate) 1943 and (2) Closed circuit T.V. system needs
Center at renovate repair;
D.C. General $50,000 d in (3) Holes in floors--drill covers
Hospital (annual 1987 needed;
maintenance (4) Carpet in children's play area
contract) Was should be
intended replaced with new safety floors;
to be (5) Inadequate air flow--poor
temporar ventilation;
y (6) Repair and replacement of doors
and ceiling
tiles necessary;
(7) Handicap access problems;
(8) Heat and humidity have caused
pneumatic
controls to malfunction; and
(9) Electrical problems.
===========================================================================================
Cost to
renovate
D.C. General
Clinics, $849,343
excluding
maintenance
costs
Public
Clinics
Benning $441,120 23 years 5,750 (1) Undersized exam rooms;
Heights (2) No departmental waiting;
Health (3) Not handicap accessible; and
Clinic (4) Poor ventilation and temperature
controls.
Walker- $728,165 20 years 6,380 (1) Deteriorated exterior;
Jones Health (2) Not handicap accessible;
Center (3) Ventilators and lavatories are
old and need
replacing;
(4) Obsolete electrical equipment
with code
violations; and
(5) Boilers, pumps, water piping, and
insulation
need replacing.
Adams Morgan $199,770 18 years 3,100 (1) Ceiling damaged;
Health (2) Inadequate air flow--poor
Center pneumatic controls;
(3) Obsolete electrical equipment
with code
violations;
(4) Various obsolete systems needing
replacement;
and
(5) Handicap access problems.
Anacostia $812,015 27 years 6,750 (1) Severe overcrowding;
Health (2) Life safety code problems;
Center (3) Patient care guideline problems;
(4) Poor HVAC and controls do not
work; and
(5) Electrical code violations.
Claridge $294,510 28 years 1,650 (1) Damaged floors, walls, and
Health ceilings from water
Center leaks and lack of maintenance;
(2) Space does not meet program
requirements--
needs complete renovation and
upgrade;
(3) Handicap access problems;
(4) Inoperative cooling system;
(5) No fresh air circulation--
filters are filthy and
clogged;
(6) No emergency power or fire alarm
system; and
(7) Electrical code violations.
Southwest $2,261,669 56 years 19,860 (1) Severe overcrowding;
Health (2) Poor space configuration;
Center (3) Numerous life safety code and
patient care
guideline problems;
(4) First and second floors need
major renovation;
(5) Replace elevator to correct code
violations;
(6) Damaged exterior, doors, windows,
and roof
need replacing;
(7) Handicap access problems;
(8) Health and cooling units are not
controllable;
(9) Poor ventilation;
(10) New chiller needed;
(11) Asbestos problems;
(12) No sink in exam room and lab;
(13) Possible underground fuel leaks;
and
(14) Normal and emergency power
systems need
replacing.
RAP, Inc. $4,288,615 40 years 36,000 (1) Exterior and interior damage and
(drug disrepair on a
treatment large-scale\c;
center) (2) Major renovation and space
utilization planning
needed;
(3) Doors, windows, and portions of
roof need
replacing;
(4) Handicap access problems;
(5) Facility would be extremely
expensive to
renovate; and
(6) Mechanical, electrical, and
plumbing systems
need replacing.
===========================================================================================
Total cost
to renovate
public $9,025,864
clinics
-------------------------------------------------------------------------------------------
\a This is the cost to renovate D.C. General Hospital. The cost to
build a new hospital and renovate the Ambulatory Critical Care Center
is $126,492,766. The survey concludes that it would be more
cost-effective to build a new, smaller facility, rather than renovate
the existing hospital complex.
\b STD clinic lost the lease to its second clinic site, which causes
this site to be severely overcrowded.
\c Building was abandoned for 4 years and exterior and interior
reflect universal, large-scale damage and disrepair.
Source: Individual survey reports provided by Dr. Marlene Kelly,
D.C. Commission of Public Health.
SCOPE AND METHODOLOGY
=========================================================== Appendix V
To analyze the District's health care budget and actual expenditures
for fiscal years 1991 through July 31, 1995, we
-- performed a detailed analysis of the District's Financial
Management System (FMS), the accounting system which tracks the
District's health care budget and actual health care
expenditures.
To address your questions on the Medicaid program, we
-- performed a detailed analysis of the MMIS database of Medicaid
claims processed during fiscal years 1993, 1994, and as of July
31, 1995;
-- interviewed (1) officials in the Mayor's office, in each of the
Commissions under the Department of Human Services, at the D.C.
Hospital Association, at all of the 13 private District
hospitals, and at First Health (the District's Medicaid claims
processor) and (2) other private health care experts;
-- reviewed Medicaid cost settlements for hospitals and long-term
care facilities for fiscal years 1993 and 1994; and
-- compared MMIS payment information, federally required Health
Care Financing Agency (HCFA) reports, and FMS accounting data.
To respond to your questions on the cost of medical services, we
-- performed a detailed analysis of the MMIS database of claims
processed during fiscal years 1993, 1994, and as of July 31,
1995;
-- interviewed (1) officials in the Mayor's office, in each of the
Commissions under the Department of Human Services, at the D.C.
Hospital Association, at all of the 13 private District
hospitals, and at First Health and (2) other private health care
experts;
-- reviewed Medicaid cost reports for hospitals and long-term care
facilities for fiscal years 1993 and 1994;
-- interviewed officials in the Commission of Public Health to
determine the District's cost reimbursement method for the 11
public clinics; and
-- performed a detailed analysis of fiscal year 1994 patient
information and expenditures from the D.C. General Hospital and
Saint Elizabeths Hospital.
To respond to your questions on the placement of health care
facilities, we
-- interviewed officials in the Mayor's office, in each of the
Commissions under the Department of Human Services, at the D.C.
Hospital Association, and at all of the 13 private District
hospitals;
-- reviewed reports analyzing and offering recommendations on the
District's health care system; and
-- performed numerous site visits, including visits to all 13
private District hospitals, D.C. General Hospital, Saint
Elizabeths Hospital, the District-run nursing home (D.C.
Village), several public clinics, and one private clinic.
To address issues on the financial condition of District hospitals,
we
-- interviewed officials in the Mayor's office, the Commission on
Mental Health Services, D.C. General Hospital, the D.C.
Hospital Association, and the 13 private District hospitals;
-- reviewed reports analyzing and offering recommendations on the
District's health care system;
-- performed a detailed analysis of financial statements for the 13
private hospitals (for the two most recent fiscal years
available audited statements were used when possible);
-- compiled and analyzed hospital cost data for all 15 hospitals
for calendar years 1993 and 1994;
-- reviewed literature on national health care trends;
-- performed a detailed analysis of fiscal year 1994 patient
information and expenditures from the D.C. General Hospital and
Saint Elizabeths Hospital; and
-- performed numerous site visits, including visits to all of the
private hospitals operating in the District, as well as D.C.
General Hospital and Saint Elizabeths Hospital to understand
their operations and observe their facilities.
To obtain information on the uninsured, we
-- reviewed numerous reports from experts on the uninsured and
-- examined the methodologies for obtaining these statistics.
During our review, we identified the following limitations to the
data we analyzed:
-- The Medicaid database contained numerous anomalies, such as
gender codes categorized as unknown and unexpected negative
values, which District officials could not explain.
-- The data from the MMIS database could not be reconciled to FMS
data.
-- Detailed Medicaid cost data for hospitals is not provided to the
District. Instead, reports with summary costs are submitted by
hospitals at varying year-ends and subsequently audited by a
District contractor. We did not examine the adequacy of the
audits. In addition, the District is at least 2 years behind in
having the audits performed.
-- Detailed demographic data is tracked by the MMIS database.
However, much of the hospital costs for fiscal years 1993, 1994,
and part of 1995 were not included in the database. As a
result, demographic information for these costs is not
available.
-- Some of the hospital information we analyzed to assess the
financial condition of the hospitals was unaudited.
-- The patient data we analyzed from Saint Elizabeths and D.C.
General Hospital were unaudited.
-- Estimates of the number of uninsured ranged from 100,000 to
125,000. More exact figures could not be obtained.
We performed our work from July 25, 1995 to December 15, 1995, in
accordance with generally accepted government auditing standards.
(See figure in printed edition.)Appendix VI
COMMENTS FROM THE MAYOR OF THE
DISTRICT OF COLUMBIA
=========================================================== Appendix V
(See figure in printed edition.)
MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix VII
ACCOUNTING AND INFORMATION
MANAGEMENT DIVISION, WASHINGTON,
D.C.
Deborah A. Taylor, Audit Manager
Phyllis Anderson, Audit Manager
Russell Hand, Audit Manager
Margaret A. Sherry, Senior Auditor
Lynn M. Dudley, Senior Auditor
Claudine Makofsky, Senior Auditor
Wilma Matthias, Senior Auditor
Christopher Warweg, Auditor
Nancy Kong, Auditor
West Coile, Auditor
Meg Mills, Communications Analyst
*** End of document. ***