District of Columbia Receivership: Selected Issues Related to Medical
Services at the D.C. Jail (Testimony, 06/30/2000, GAO/T-GGD-00-173).

The D.C. Jail's medical care facility was placed under court-ordered
receivership in August 1995 after the District was held in contempt for
repeatedly failing to carry out court orders. These orders arose from
long-standing litigation intended to help ensure adequate medical
services to prisoners. The receivership is scheduled to expire in August
2000. In January 2000, the receiver awarded a one-year contract, with
four option years, to a private, not-for-profit firm to provide medical
services to individuals housed at the D.C. jail. This testimony answers
the following four questions: (1) What are the costs of providing
medical services at the D.C. Jail as compared with similar
jurisdictions? (2) What would constitute an acceptable level of medical
service and staffing at the jail? (3) What effect did the contracting
process have on medical service costs? (4) Did the failure of the
receiver's employees to resign from their positions before being awarded
the contract violate D.C. laws or regulations?

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-GGD-00-173
     TITLE:  District of Columbia Receivership: Selected Issues Related
	     to Medical Services at the D.C. Jail
      DATE:  06/30/2000
   SUBJECT:  Correctional facilities
	     Prisoners
	     Health care services
	     Government contracts
	     Procurement regulations
	     Health care personnel
	     Health resources utilization
	     Comparative analysis
	     Cost effectiveness analysis
	     Municipal governments

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GAO/T-GGD-00-173

United States General Accounting Office
GAO

Testimony

Before the Subcommittee on the District of
Columbia
Committee on Government Reform
House of Representatives

For Release on Delivery
Expected at
10:00 a.m. EDT
on Friday
June 30, 2000
GAO/T-GGD-00-173

DISTRICT OF COLUMBIA RECEIVERSHIP
Selected Issues Related to Medical Services at

the D.C. Jail

Statement by Laurie E. Ekstrand
Director, Administration of Justice Issues
General Government Division

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 (188653)

Statement
District of Columbia: Contracting for Medical
Services at the D.C. Jail
Page 8                           GAO/T-GGD-00-173
Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss selected
topics concerning the District of Columbia Medical
Receiver's contract for medical and mental health
services1 at the D.C. Jail.  As you know, the D.C.
Jail's medical care facility was placed under
court-ordered receivership in August 1995, after
the District was held in contempt for repeatedly
failing to implement court orders.  These orders
emanated from long-standing litigation intended to
ensure adequate medical services to jail inmates.
The Receivership is scheduled to expire in August
2000. In January 2000, the Receiver awarded a 1-
year contract, with 4 option years, to a private,
not-for-profit firm to provide medical services to
individuals housed at the D.C. Jail.  Performance
on the contract began in March 2000.

Based on your request, our work has focused on
four questions: (1) What are the costs of
providing medical services at the D.C. Jail as
compared with jurisdictions said to be similar?
(2) What would constitute an acceptable level of
medical service and staffing at the jail? (3) What
effect did the contracting process have on medical
service costs? (4) Did the failure of the
Receiver's employees to resign from their
positions prior to being awarded the contract
violate D.C. law or regulations? As you know, we
have been conducting our work for only a matter of
a few weeks, so we do not have complete answers to
all of these questions.

To answer these questions, we analyzed available
cost, staffing, and contracting information and
conducted interviews with cognizant officials.
Specifically, we spoke with officials from the
Office of the Receiver for Medical and Mental
Health Services, the Office of the Corrections
Trustee, the Office of Corporation Counsel, and
the Department of Corrections (DOC). We also spoke
with the District's Deputy Mayor for Public Safety
and Justice. Further, we spoke with counsels for
both the Receiver and for the plaintiffs whose
suit resulted in the D.C. Jail's being placed in
receivership. In addition, we spoke with officials
of all three private companies that made offers on
the contract. The Special Officer-appointed by the
U.S. District Court for the District of Columbia
and charged with overseeing the Receiver's
activities-cited constraints placed on her by the
Code of Judicial Conduct and declined to be
interviewed. We performed our review from May 17
to June 27, 2000, in accordance with generally
accepted government auditing standards.  We did
not independently verify the cost and staffing
data or the other information we obtained, nor did
we evaluate the individual proposals submitted in
response to the solicitation.

     In this statement, I would like to make the
following points:

ï¿½    Our comparison of contract budget data for
medical services at the D.C. Jail and two
reportedly comparable facilities--in Baltimore and
Prince George's County, Maryland--indicated that
the D.C. Jail's per capita costs were higher.
Officials with whom we spoke during our review
agreed that the D.C. Jail provided certain medical
services-and had staffing levels-usually not
provided by other jurisdictions. Accordingly, the
cost differences between the D.C. Jail and those
in Baltimore and Prince George's County are likely
due, in part, to differences in staffing levels,
which in turn are likely due, in part, to the
types of medical services provided.  For example,
the inmate to staff ratio, as reported by the
Office of the Corrections Trustee, at the D.C.
Jail's medical facility is 13.4 to 1; compared
with 74 to 1 in Baltimore and 48 to 1 in Prince
George's County. The fact that the D.C. Jail
provides a fully staffed on-site pharmacy and
mental health and dental services, whereas
Baltimore and Prince George's County provide these
services differently, offers a context for
understanding some of the differences in the
inmate to staff ratios. Officials with whom we
spoke and documents we reviewed indicated that a
court-ordered Remedial Plan is the primary reason
why the D.C. Jail provides medical services and
has higher staffing levels than other
jurisdictions. The Trustee felt, however, that
adequate medical services could be provided with
fewer staff and at lower cost.

ï¿½    There is no single specific threshold that
determines what an acceptable level of medical
service and staffing is at a jail.  According to
correctional medicine experts, generally, the
level of service and staffing is a function of
many factors, including the situation and
circumstances to be addressed.  It is also a
function of the specific constraints and demands
placed on the service delivery system at a
particular location. Standards, such as those
developed by the National Commission on
Correctional Health Care (NCCHC), define minimum
recommended medical service requirements for jails
to voluntarily obtain accreditation.  For example,
the standards include "essential" requirements,
such as inmate receiving screening, and
"important" requirements, such as pregnancy
counseling for female inmates.  While the
standards recommend at least 1 full-time
equivalent  (FTE) physician in jails with an
average daily population of 500 or greater, they
also state that the staffing level at a facility
depends on a range of factors, including the type
and scope of the medical services being offered.
ï¿½    The current contract maintains levels of
medical service and staffing that were already in
place at the D.C. Jail, but possibilities exist to
reduce future contract costs. The current contract
can be modified at any time. In addition, it can
be recompeted at its current or scaled-back levels
of service and staffing when its first year ends.
The solicitation that resulted in the current
contract did not preclude offerors from submitting
proposals that would reduce staffing and costs
over the existing levels, as long as quality
health care services would be provided. The
solicitation encouraged offerors to submit such
"alternate" proposals for providing quality
medical services differently or more economically
than they were currently being provided. In
addition, the Receiver decided, in consultation
with District officials, to require offerors to
submit "comparison" proposals that maintained the
current levels of service and staffing at the
jail. According to officials we spoke with, the
District sought to maintain services at their
current level in order to ensure that the
Receivership is successfully terminated in August
2000 and control of the jail is returned to the
District. Each of the three offerors submitted a
comparison and an alternate proposal.  The
evaluation committee rated all of the proposals.
The Receiver and the committee determined that
none of the alternate proposals provided specific
enough information to ensure that the alternative
approach would maintain the same level of medical
services as did the comparison proposals.  Thus,
the final recommendation of the committee was to
endorse a comparison proposal.

ï¿½    The Receiver employees that were awarded the
contract were not subject to D.C. Personnel
Regulations because they were not D.C. employees.
According to these personnel regulations, a
District employee can make an offer on a contract,
but generally cannot be awarded one when still in
District employment status. Separately, the D.C.
Contract Appeals Board (CAB)-in a May 24, 2000,
ruling on the protest of one of the losing
offerors-stated that, while there was not proof
sufficient to challenge the award, certain actions
by the Receiver gave an appearance not conducive
to confidence in the fairness of the procurement.
CAB nevertheless denied the protest and, in June
2000, denied the protester's motion to reconsider.

Background
     In 1971, pretrial detainees at the D.C. Jail
filed suit in U.S. District Court alleging that,
in violation of their civil and constitutional
rights,2 they and others were denied minimally
adequate medical care and treatment while in
custody. In 1975, a group of post-trial inmates at
the jail brought suit on similar grounds, and the
cases were eventually consolidated.3  Between 1971
and 1994, the Court entered several remedial
orders, including a detailed Initial Remedial Plan
submitted to the court in 1994 by the Special
Officer. In July 1995, the court determined that
DOC was in continued noncompliance with the 1994
Remedial Plan and entered an order to remove
control and operation of medical and mental health
services at the D.C. Jail from DOC and place them
in receivership under the Court's supervision.
The Receivership commenced in August 1995 and is
set to expire in August 2000 unless the court
finds cause to extend the appointment.

     The court order appointing the Receiver
required that the Receiver establish procedures
and systems within DOC to ensure that compliance
with court orders would be maintained after the
receivership was terminated. In 1998, the Receiver
decided to issue a solicitation to acquire the
services of a private company in providing ongoing
medical services at the D.C. Jail after the
Receivership ends.

     A five-member committee-consisting of the
Court's Special Officer, two DOC representatives,
and one representative each for the Corrections
Trustee and the plaintiffs' counsel-evaluated the
proposals.  The committee recommended to the
Receiver that one of three firms that had
submitted proposals be selected as the awardee.
The Receiver independently evaluated all three
proposals; concurred with the recommendation of
the committee; and, as the contracting officer,
made the decision to award the contract to that
firm.

D.C. Jail Medical Costs Higher than Other
Jurisdictions, But Caution Needed in Interpreting
Differences
We compared available reported budget and staffing
data for the D.C. Jail with budget and staffing
data for the Baltimore City Detention Center
(BCDC) and the Prince George's County Correctional
Center (PGCCC).  According to information provided
by the Corrections Trustee, these jurisdictions
are said to be comparable to the D.C. Jail. This
comparison serves as an illustration only,
because, as discussed below, correctional medicine
experts-including those retained by the Office of
the Corrections Trustee-strongly caution against
comparing costs across correctional systems.  It
is important to note, however, that officials with
whom we spoke and documents we reviewed during our
review indicated that the D.C. Jail provides
certain medical services not usually provided by
other jurisdictions.

Our comparison of information provided to us
showed that the reported per capita costs at the
D.C. Jail-at $20.56 per day-were higher than at
BCDC ($8.66 per day) and at PGCCC ($5.48 per day).
These cost differences reflected, among other
things, differences in staffing levels and in the
types of medical services offered by these
jurisdictions.  Specifically, in terms of
staffing, the D.C Jail contract has 125.2 FTE
positions for an average population of 1,650
inmates,4 while BCDC's has 44.04 FTE positions for
an average population of 3,100 inmates, and
PGCCC's has 26.2 FTE positions for an average
population of 1,258 inmates.  The Trustee reported
that these staffing levels result in inmate-to-
staff ratios of 13.4 to 1, 74 to 1, and 48 to 1
for the D.C. Jail, BCDC, and PGCCC facilities,
respectively. In terms of the reported number of
physicians, the D.C. Jail has 10.85 FTE physician
positions, while BCDC has 2.3 FTE physician
positions, and PGCCC has 1 FTE physician position.

In terms of medical services, we judgmentally
identified and compared the broad level of mental
health, dental, and pharmaceutical services
offered at these jurisdictions.  The D.C. Jail
offers fully staffed, on-site mental health,
dental, and pharmaceutical services.  BCDC offers
on-site mental health services, emergency dental
services, and pharmaceutical services through a
regional pharmacy that serves other jurisdictions.
PGCCC offers access to mental health services but
does not have an on-site facility; it also offers
limited on-site dental services and pharmaceutical
services through its own pharmacy located in
another state.

 Several officials we spoke with and documents we
reviewed indicated that the D.C. Jail's current
budget-and thus its relatively high per capita
cost-reflects the level of medical services and
staffing required by the 1994 court-ordered
Remedial Plan, as amended by annual budgets
submitted by the Receiver.  The Remedial Plan is a
detailed document developed by the Court's Special
Officer in consultation with medical experts and
the parties to the litigation.  The Plan required
the defendants to provide a wide range of medical
services, such as mental health (including suicide
prevention), dental, and pharmaceutical services.
The Plan also established the policies,
procedures, and staffing structure needed to
accomplish its requirements.  To provide the
medical services, the Plan required an original
staffing level of 152.4 FTE positions, including
16.5 FTE physician positions.  The privatization
contract reduced the number of positions to 125.2
FTEs.  The Trustee, however, has indicated that
the current levels of staffing and costs are above
what is required to provide adequate medical
services at the D.C. Jail.

Our review of information on correctional costs
revealed that comparing cost data across
jurisdictions could be highly problematic.  Recent
publications, including The Corrections Yearbook,
published by the not-for-profit Criminal Justice
Institute, caution that jail medical cost figures
may not be easily comparable across jurisdictions.
This is because jurisdictions may include (or
exclude) the cost of different types of services
in their medical cost figures.  For example, some
jurisdictions may include costs for mental health
services and for inpatient hospitalization, while
others may not.  Also, they may or may not include
items such as employee fringe benefits and
renovations of medical services' space.  Finally,
there may be different ways of tabulating and
reporting costs

No Single Threshold Defines Acceptable Levels of
Medical Service and Staffing
There is no single factor or specific threshold
that delineates the point at which an acceptable
level of medical care is achieved in a jail.
According to correctional medicine
experts-including two consultants retained by the
Office of the Corrections Trustee-the acceptable
level of service and staffing is a function of
many factors, including the medical situation and
circumstances to be addressed.  It is also,
according to the Office of Corrections Trustee, a
function of the specific constraints and demands
placed on the service delivery system at a
particular location.

Regarding "constitutional" standards of medical
care, pursuant to the Eighth Amendment, the
government has an obligation to provide medical
care to prisoners.  The U.S. Supreme Court, in
Estelle v. Gamble,5 concluded that "deliberate
indifference to serious medical needs of prisoners
constitutes the unnecessary and wanton infliction
of pain proscribed by the Eighth Amendment."  The
Estelle Court noted that negligence alone did not
amount to a constitutional violation.  However,
such cases tend to arise in the negative, when
deficiencies in a correctional operation, such as
the failure to deliver services to a prisoner in a
reasonable time, reflect an unconstitutional level
of care in particular situations.

Accreditation standards developed by NCCHC for
medical services at jails set the minimum
recommended requirements to achieve voluntary
accreditation.6   The standards we reviewed
include 33 "essential" requirements, such as
inmate receiving screening, diet and exercise, and
suicide prevention.  They also include 36
"important" requirements, such as hospital and
specialized ambulatory care, and pregnancy
counseling for female inmates.  In terms of
staffing, the standards recommend that there be at
least one FTE physician in jails with an average
daily population of 500 or greater. However, the
standards also state that the numbers and types of
health care professionals required at a facility
depend on a range of factors, including the type
and scope of the medical services being offered.

The contract requires the D.C. Jail to be
accredited by NCCHC or JCAHO within 12 months of
the contract's inception.  BCDC and PGCCC are
currently accredited by NCCHC, according to the
Office of Corrections Trustee.

Possibilities Exist to Reduce Future Contract
Costs
The current contract maintains levels of medical
service and staffing that were already in place at
the D.C. Jail, but possibilities exist to reduce
future contract costs. The contract includes a
provision under which the contractor is to return
on a quarterly basis any unused funding to the
District. In addition, the contract can be
modified at any time or recompeted at existing or
scaled-back levels when the first year ends.

The solicitation to acquire medical services for
the D.C. Jail did not preclude offerors from
submitting proposals that would reduce staffing
and costs over the existing levels, as long as
quality health care services would be provided.
The solicitation encouraged each offeror to submit
an "alternate" proposal for providing quality
health care services differently or more
economically than that specified in the comparison
proposal.  The solicitation indicated that the
offerors should not feel constrained by the
parameters of the comparison proposal, including
the FTE levels and positions.  Accordingly, each
of the three offerors submitted an alternate
proposal.

The Receiver, in consultation with District
officials, made it a requirement that each offeror
also submit a "comparison" proposal that would
maintain the existing staffing levels and
positions for at least 1 year.  According to the
DOC Director and the Office of Corporation
Counsel, they supported this decision because they
felt that maintaining the existing service levels
offered the best means for obtaining court
approval to end the Receivership in August 2000
and return control of the Jail's medical facility
to the District.  The decision also sought to
ensure that the quality of medical care would not
decline and again result in litigation, according
to District officials.

The evaluation committee initially rated all six
of the proposals (three comparison and three
alternate).  The Receiver and committee concluded
that none of the alternate proposals provided
specific enough information to ensure that the
alternate approaches would maintain the same level
of medical services as did the comparison
proposals.  Accordingly, the alternate proposals
were not evaluated by the committee in its final
review of proposals.  The committee recommended to
the Receiver that he issue the contract to the top-
rated company to implement its comparison
proposal.

Receiver Employees Were Not Subject to D.C.
Personnel Regulations
     The firm that was awarded the contract to
provide medical and mental health services at the
D.C. Jail was constituted of employees working for
the Receiver, not for the District government.
Under D.C. Personnel Regulations, a District
employee may not be a party to a contract with the
District government unless a written determination
has been made by the head of the procuring agency
that there is a compelling reason for contracting
with the employee.  A District employee can make
an offer on a contract, but generally cannot be
awarded the contract while still in D.C.
employment status.  In this case, however, the
winning firm was made up of employees of the
Receiver rather than the District government, and
they were awarded a contract with the Receiver.
Therefore, the personnel regulation did not apply
in this context.

     We would note that the D.C. Contract Appeals
Board (CAB) ruled in May 2000 on a protest by a
losing offeror in this procurement.  The protester
asserted, among other things, that the Receiver
showed bias in favor of the company (the awardee)
formed by the incumbent Medical Director.  The
protestor did not specifically raise the issue of
the employees' failure to resign prior to the
award. CAB denied the protest, finding that there
was not proof of bias sufficient to challenge the
award.  However, CAB noted that certain of the
Receiver's actions gave an appearance not
conducive to confidence in the fairness of this
procurement.

Contacts and Acknowledgements
     For further information regarding this
statement, please contact Laurie E. Ekstrand or
Evi L. Rezmovic on (202) 512-8777.  Individuals
making key contributions to this statement
included Seto J. Bagdoyan, John Brosnan, Niambi
Carter, Carole Hirsch, Jan B. Montgomery, and
Kristen Plungas.

_______________________________
1 The term "medical services" will be used in the
remainder of the testimony to refer to both
medical and mental health services.
2 See Campbell v. McGruder, C.A. No. 14 62-71
(D.D.C.).
3 See Inmates of D.C. Jail v. Jackson, C.A. No. 75-
1668 (D.D.C).
4 The number of FTE positions is obtained by
dividing the total number of hours worked by 2,080
hours (40 hours per week times 52 weeks per year).
The source of the average population of inmates is
from an analysis prepared by the Office of the
Corrections Trustee.
5 429 U.S. 97 (1976).
6 NCCHC is a not-for-profit accreditation
association that includes the American Medical
Association and the American Jail Association.
There also exist other accreditation
organizations, such as the American Correctional
Association and the Joint Commission on
Accreditation of Health Care Organizations
(JCAHO). We focused on NCCHC's standards because,
as noted in the text, the D.C. Jail contract
requires the jail to be accredited by NCCHC or
JCAHO, and we were only able to obtain the NCCHC
standards within the time frame of this review.
*** End of document ***