Status Report Prison Medical Care

1. Status ReportPrison Medical Care J. Clark Kelso Federal Receiver January 26, 2011

2. Overview • Summary of Court Orders • Key Performance Measures • Accountability for Costs of Medical Care • Road Map Forward

3. Summary of Court Orders • 2002 Stipulated Injunction (Plata) • Requires compliance with CDCR Medical Policies & Procedures consistent with 8th Amendment. • 2006 Order Appointing Receiver • Receivership shall cease when Court is satisfied that State has the will, capacity and leadership to maintain a system of providing constitutionally adequate medical care services to class members. • 2008 Order Approving 5-Year Turnaround Plan of Action • Court finds the Plan’s six goals to be necessary to bring system up to constitutional standards. • Other Cases (Coleman, Perez, and Armstrong).

4. Key Performance Measures:Turnaround Plan Progress • Overall • 70% of Action items completed (33 of 47) • 9% On schedule (4 of 47) • 21% Behind schedule (10 of 47) • Elements of the Turnaround Plan of Action • Clinical staffing • Medical care • Custody access to care • Allied support • Facilities • Quality accountability

5. Key Performance Measures: Turnaround Plan Progress • Clinical Staffing (substantially complete) • Hiring: 90% target for approved clinical positions • Physicians • Mid-Levels • Nurses • Turnover: <10% Target • Physicians • Mid-Levels • Nurses • High use of registry contracts and overtime • Medical Loss Ratio = 81%

6. Key Performance Measures: Turnaround Plan Progress • Medical Care (50% complete) • Primary care (50% complete) • Chronic care (40% complete) • Emergency medical response system (complete) • Specialty care and hospitalization (75% complete) • Telemedicine expansion (15% complete) • Focus on Cost Containment and Quality Improvement ($408 million savings/cost avoidance) • Outside providers ($340 million savings/cost avoidance) • Third-party administrator • Capped rates/statewide network provider • Utilization management • Registry use • Other measures ($68 million savings)

7. Key Performance Measures: Turnaround Plan Progress • Custody Access to Care (substantially complete) • Every month, 500,000 inmates have appointments for medical, mental health, dental and specialty services. • To ensure access, we hired approximately 2,000 “health care access officers” to assist in escorts. • Target is to escort 85% or more of inmates to appointments. Target currently being met. • Custody issues block < 1% of appointments. • In mental health, still have large backlogs of inmates waiting for beds for treatment.

8. Key Performance Measures: Turnaround Plan Progress • Allied Support (30% complete) • Electronic health care scheduling (25% complete) • Electronic medical records (25%) • Dictation and transcription (50% complete) • Mental health tracking system (substantially complete) • Basic electronic medication administration records and central pharmacy (15% complete) • Labs and radiology (30% complete)

9. Key Performance Measures: Turnaround Plan Progress • Facilities (30% complete) • San Quentin construction completed by December 2009 – delivered early and under budget (completed) • Avenal State Prison projects (completed) • AB 900 Health care-related construction ($2.362 billion) underway • 1 Consolidated care center (1,722 beds) • 3 Renovated Juvenile Justice facilities (3,894 beds) • Improvements at prisons • Designation of health care hub prisons with inmates assigned pursuant to new medical classification system

10. Key Performance Measures: Turnaround Plan Progress • Facilities Timeline • 2006-2008: Planning for 10,000-bed project ($6 billion) and facility upgrade ($1 billion) • February 2009 – August 2009: Begin downsizing for smaller scope (first down to 3 new facilities, then down to 1 new and 3 DJJ) • September 2009 – Present: Delegation of construction from Receiver to CDCR and further downsizing to reflect change in project methodology and achieve greater efficiencies.

11. Key Performance Measures: Turnaround Plan Progress • Quality Accountability (40% complete) • Dashboard (substantially complete) • All institution CEOs hired (complete) • Annual OIG assessments (1st round complete, second round just starting) • Annual death reports (complete) • Chronic care reports (30% complete)

12. Key Performance Measures:OIG Inspections • 33 of 33 Institutions Completed • Average Score = 71.9% (slight upward trend over the year – trend line goes from 69% to 74.5%) • High score=83.2% (Folsom) • Low score=62.4% (High Desert) • Low Scores in: • Access to providers (overcrowding related); • Medication management (overcrowding related). • High Scores in: • Continuity of care; • Primary care provider responsibilities; • Nurse responsibilities.

13. Key Performance Measures:Death Reports Overall death rate has dropped 10-12%.

14. Key Performance Measures:Death Reports Rate of likely preventable deaths decreased by 82%. Rate of possibly preventable deaths decreased by 7%.

15. Key Performance Measures:Chronic Care • Diabetes Control – Red • HbA1c Goal: 85% of patients have HbA1c < 8%. • For 2009, only 76% had < 8%. • LDL-C Goal: 85% have LDL-C < 100 mg/dL. • For 2009, only 66% had < 100 mg/dL. • Microalbumin screen goal: 85% of patients screened. • For 2009, only 57% had received screening. • Asthma Control -- Green • Goal: Ratio of short-acting beta agonist (SABA) to inhaled corticosteroid (ICS) prescription < 2:1. • As of August 2010, ratio was 1.75. • 21 institutions met goal; 3 outliers near or above 3:1 being examined. • Colon cancer screening and breast cancer screening – Red • Soon to come: HepC treatment; HIV treatment.

16. Accountability for Costs of Medical Care • From 2006 to 2008, Receiver initiatives were funded through informal “Genest Letters” outside normal process. • In 2008, the current Receiver began reintegrating planning and expenditures back into normal budget process. Receiver has invited audits by SCO, BSA and OIG. • The Receiver began cost-containment initiative in early 2009, and expenditures, which were spiraling upward, came down. • We have largely completed the process of working with Finance to bring our budgeting back into normal process. • The $811 million cut in last year’s budget was a figure set by the Governor’s Office (an additional reduction of $9 million was approved by the Legislature). I promised to do whatever I could to secure savings.

17. Accountability for Costs of Medical Care 2nd Receiver 1st Receiver Data points for 2010-11 and 2011-12 are budgeted amounts; all other points are actual expenditures.

18. Road Map Forward • Plata – Medical • Fund and finish Turnaround Plan. • Clear process hurdles to construction, complete construction, and activate. • Improve OIG inspection scores. • Reduce population to reduce overcrowding.