📋
Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Los Angeles County Grand Jury • 2010-2011

Civil Grand Jury County of LOS Angeles

Published: June 30, 2011 58 pages
View PDF View Full Original

Findings 17 findings

F1 Page 78
According to the LASD, inmates released from jail are rearrested at a rate of 42.2% within the first six (6) months. After six (6) months of release, the recidivism rate for rearrest increases to 57.4%. Two (2) of the strongest, most consistent predictors contributing to recidivism among County jail inmates are lack of employment and substance abuse. Data indicates there is a high likelihood inmates will return to jail if not provided with guidance and direction within eight (8) hours of release.
F2 Page 78
At Pitchess, the CGJ observed a marked difference in the environment, interactions and activities in housing units where classes were and were not being held. Inmates not involved in classes were in crowded dormitory facilities, playing cards, watching TV, pacing or engaged in minimal constructive activities. In contrast, inmates enrolled in the MERIT program who are housed separately were in classrooms filled to capacity or engaged in listening to dynamic motivational speakers’ presentations. Several CGJ observers were moved to tears by the sincerity and focus demonstrated by these inmates.
F3 Page 78
According to the Los Angeles District Attorney’s website, the County of Los Angeles has approximately fourteen hundred (1,400) known street gangs. External community support organizations note that gang leaders are recruiting new members at a younger age with some new members being fourth generation gang members. It is estimated that of the 85,000 gang members in Los Angeles County, approximately: 4. 90% will be arrested by the age of 18 5. 75% will be arrested twice by the age of 18 6. 95% will not finish high school 7. 60% will be in prison or dead by the age of 20
F4 Page 91
Lack of a uniform pre-payment billing process throughout the facilities adversely affects the level of ORSA enrollment. ORSA is preferable because reimbursements are higher for the uninsured ORSA population from the State and Federal cost reimbursement pools. The Registration PRW provides patients with information regarding available low- cost/no-cost programs during the patients’ financial screening. While the process from preliminary medical evaluation up to the PRW registration is generally consistent across the facilities, each hospital’s practices differ after the PRW registration. At LAC+USC Pre-Payment billing envelopes are distributed only if the patient returns after they are seen by the doctor and requests this information from the Registration PRW. At Olive View, Pre-Payment envelopes are not provided at any time. If patients would like to use this form of payment, they must visit the cashier and request this information. For these two facilities, patients who specifically request the Pre-Payment plan typically are aware of the program before their hospital visit as noted by facility staff. Since the Registration PRW does not provide the envelopes unless requested, this indirectly encourages a greater number of patients to apply to ORSA. From a program reimbursement perspective, Table 5 shows LAC+USC and Harbor-UCLA Pre-Payment population as compared to the ORSA population in Fiscal Years 2007- 2010. Alternatively, Harbor-UCLA automatically issues Pre-Payment billing envelopes with discharge materials to each patient with a LAC address. In this facility, patients decide between immediate remuneration or returning to the financial office and applying for ORSA, Medi-Cal, or other low income insurance programs. This method of distribution indirectly encourages more Pre-Payment applications. From an in-house billing and collection perspective, Pre-Payment is preferable, as the facility initially collects more than ORSA (until DHS seeks reimbursement funds). However, these methods influence patients with adequate financial means to apply for the Pre-Payment plan as income verification is not required. Table 5 shows that the number of patients at Harbor-UCLA claim Pre-Payment is significantly higher, despite a considerably larger LAC+USC patient volume: Table 5. Pre-Payment Plan and ORSA Visits, LAC-USC and Harbor-UCLA UCLA, FY 2007-2010 Prepayment -Number ORSA - Number of visits Total Year Facility of visits and percentage and percentage of total Visits of total visits visits LAC-USC 691,046 16,271 2.35% 311,702 45.11% FY 2009-10 Harbor-UCLA 344,401 27,239 7.91% 94,664 27.49% FY 2008- LAC-USC 521, 960 19,124 3.66% 190,636 36.52% 09 Harbor-UCLA 337,992 31,907 9.44% 94,508 27.96% LAC-USC 505,881 25,380 5.02% 207,105 40.94% FY 2007-08 Harbor-UCLA 317,708 43,138 13.58% 99,571 31.34%
F5 Page 91
Facilities have different practices and procedures regarding the Extended Payment Plan Policy causing difficulties in collections. Establishing more EPP usage can potentially improve overall collection rates. Patients would rather pay off their debt incrementally than have their accounts transferred to debt collectors. 66 2010 – 2011 LOS ANGELES COUNTY CIVIL GRAND JURY Increasing the use of EPP appears also to be an incentive for hospitals. Hospital staff noted that EPP allows the hospital to recoup some of the cost of service (an estimated average of $0.60 for every dollar of cost according to staff). Furthermore, it is important that patients are aware of all payment and coverage options, particularly ones that encourage patient responsibility for service payment. The hospitals’ practice of the EPP varies.4 LAC+USC reviews contracts and monthly minimums with the patient but then transfers the account to outside collection agencies. These outside vendors will communicate with the patients to receive their monthly payments and levy a service surcharge of 15-20% of the funds collected. Alternatively, Olive View manages and collects these EPP payments in-house and limits their use of outside collection agencies. Harbor-UCLA follows a similar method and sends the EPP accounts to collections only if the account becomes delinquent. Currently, County hospitals limit their efforts to educate patients regarding the EPP option. The CGJ’s interviews revealed that the collection levels for EPP accounts appear to be relatively higher than other types of accounts. (For example, Olive View staff indicated that over 80% of EPP accounts are successfully collected.)5
F6 Page 92
Patient accounts classified as “Self-Pay” may be a misnomer; they may never pay. At the initial financial screening, the Registration PRW first categorizes patients as Medi- Cal or Self-Pay. If the patient is approved for a low-cost/no-cost program, the categorization changes according to the accepted programs.6 However, if the patient does not pay their share of cost, their account becomes delinquent and is transferred to collection. The categorization then shifts to Self-Pay. Although current write-offs include the Self-Pay population, there are a variety of residual account types that fail to be collected in-house. Table 6 outlines the types of patients who are initially classified as Self-Pay patients, and the accounts that are referred to the Self-Pay population. Table 6. Self Pay Patient Characteristics Homeless Ineligible for programs Out of county residents Classified Self-Pay Insurance co-pay Patients Patients who have not received financial screening Non-compliant (undocumented immigrants, patients reluctant to provide insurance information to avoid deductable, and patients disinclined to provide information that disqualifies them for low-cost/no cost programs.) Pending and denied Medi-Cal applications Residual Accounts that Residual costs from patient responsibility or share of cost (Medi-Cal, Pre- Shift to Self-Pay payment, ORSA, ATP) While the hospital system, molded by policy and regulation, is designed to provide low income populations with more access to medical care and to prevent hospital facilities from making medical decisions based on economic reasons alone, it is vulnerable to public misuse. There are numerous anecdotal references about patients who have the 4 See Extended Payment Plan 5 Note that the hospitals’ staffs were not able to provide detailed data on the volume and charge totals of the EPP accounts 6 ATP, ORSA, Medi-Cal, Medi-Care, Self-Pay 2010 – 2011 financial means to pay for their own medical care. However, they opt to withhold critical information and, at times, even provide false information to avoid paying their medical bills. Quantifying the level of fraud or public abuse of the medical system is difficult and beyond the scope of our investigation. But in the CGJ’s analysis, it appears there are areas within the public hospital medical care system that are vulnerable to public abuse.
F7 Page 93
Although there has been confusion as to the difference between the total service charge and actual cost of service, the bottom line is: a significant loss to the County. There is a difference between the actual cost and the charged amount for rendered services. The actual cost represents the direct cost to the hospital providing treatment. The charged amount represents the service cost plus overhead. During patient billing and collection, the facilities and collection agencies seek payment for the service charge. If the account becomes delinquent and ultimately declared by the County Treasurer and Tax Collector (TTC) to be uncollectible, the service charge is written off. The total service charge written off is the amount reported and released publicly. However, the actual service cost is lower, estimated by management to be approximately 53% of the service charge. Table 7 lists the total service charges for the three (3) hospitals, as well as the estimated actual costs for service based on this reported cost-to-charge ratio: Table 7. Estimated Total DHS Medical Care Service Charges and Costs Estimated Actual Cost of Service Total Charges for (Approx. 53% of Year Service Total Charge) FY 09-10 $733,685,430 $395,676,552 Note: These costs include the ORSA, ATP, Medi-Cal and Self-Pay accounts. DHS then uses Federal and State funds to reimburse the hospital facilities for their actual costs.
F8 Page 78
Research shows that before you can prepare parolees for a job by teaching job skills, it is imperative that you prepare their minds for a new and different way of thinking when they reenter society upon release. According to a 2010 publication by the LASD on EBI, the LASD recognizes that inmates who are better prepared mentally, psychologically and educationally for transition and reentry into the community have a much higher success rate. The principles of EBI are designed specifically to assist inmates in their transition from custody to civilian life.
F9 Page 78
LASD previously had a long-term contract with a school district for instructors to provide EBI training to inmates. Negotiations are underway for a new contract that is expected to be finalized by mid-2011. At that time, instructors will teach EBI courses through the contracted organization. Ultimately, the goal over the next two (2) years is to develop an educational program to administer EBI course work to inmates in conjunction with a Federal workforce investment program. 54 2010 – 2011 LOS ANGELES COUNTY CIVIL GRAND JURY
F10 Page 79
Custody Assistants (CAs) are LASD employees working in the jail system to manage inmates. Some CAs have been provided limited training to instruct inmates in various programs such as parenting and anger management. The amount of time spent in training varies from ten (10) hours to thirty-two (32) hours with additional workbook and video instruction. This limited training appears to be inadequate in contrast to four (4) year bachelor degrees and teaching credentials required by school district teachers. The effectiveness of the CA instructors is measured and may need to be assessed for effectiveness. This issue did not appear to be a concern with females at CRDF as much as the male population at other jails.
F11 Page 79
Concerns were expressed during this investigation from various organizations about limited access of inmates to civilian, non-sworn personnel if CAs are being charged with teaching and acting as case managers. As case managers, they seek to ensure participants have tools needed to reintegrate into the community. The concern was whether inmates will relate to and confide in LASD employee instructors with the same level of trust as they would to a civilian teacher. While the CGJ understands the security and safety issues related to uncontrolled access of inmates to civilians, questions were raised about the LASD attempting to limit external involvement with inmates. Of particular concern was whether an inmate’s needs to connect with family, make contact with their attorneys and receive meaningful assistance was adequately met.
F12 Page 79
The Inmate Welfare Fund (IWF) is a fund derived from revenue sharing contracts such as inmate phone calls, vending machines and commissaries where inmates can purchase food and personal items with money put into an account by their families. The fund generates approximately $47 million a year and is “to be expended for the benefit, education and welfare of inmates.” The IWF allocates 51% for inmate programming and services (which includes EBI courses) and 49% for jail maintenance. The Inmate Welfare Commission is an advisory body which makes
F13 Page 79
In addition, the CGJ found that the EBI program faces four (4) major obstacles:
F14 Page 79
Inability to effectively translate course material for the Spanish speaking population
F15 Page 79
Lack of adequate exposure to program benefits by the Board of Supervisors and other influential sectors of County government
F16 Page 79
Effectively marketing the program internally to local government leaders and externally to potential corporate partners
F17 Page 79
Apprehension of participation by male inmates due to internal jail house politics and gang peer pressure

Recommendations 10