STATE Or CALIFORNIA EDMUND G. BROWN JR., COMMISSION ON .
STATEOr CALIFORNIAEDMUND G. BROWN JR., GovernorCOMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY11th & L BUILDING,SUITE 550, (916) 445-2125SACRAMENTO 95814Ch.irmllnNATHAN SHAPELLBeverly HillsVicfl--ChairmllnDONALD G. LIVINGSTONLos AngelesALFRED E. ALOUISTSenator. San JoseMAURICE RENE CHEZLos AngelesDAVID P. DAWSONSan FranciscoJACK R. FENTONAssemblyman, MontebelloEDWARD M. FRYERPortola ValleyRICHARD D. HAYDENAssemblyman, CupeninoMILTON MARKSSenator. San FranciscoMANNING J. POSTBeverly HillsLLOYD RIGLERLos AngelesALAN E. ROTHENBERGSan FranciscoCARMEN H. WARS CHAWLos AngelesL. H. HALCOMBExecutive Director SUPPLEMENTAL REPORTADMINISTRATION OF THEMEDI-CAL PROGRAMOF THESTATE DEPARTMENT OF HEALTHSTATE OFCALIFORNIA
SUPPLEMENTARY REPORT ON THE ADMINISTRATIONOF THE STATE MEDI-CAL PROGRAMSEPTEMBER 1977TABLE OF CONTENTSPAGEI.II.III.IV.NINETEEN MONTHS OF PROGRESS--AN OVERVIEW1SUMMARY OF JANUARY 1976 REPORT5RESPONSE TO RECOMMENDATIONS7A.ADMINISTRATIVE COSTS7B.FEES AND QUALITY OF CARE7C.ELIGIBILITY STANDARDS11D.BENEFIT STRUCTURE12E.FISCAL INTERMEDIARYF.PREPAID HEALTH PLANSG.FOUNDATIONS FOR MEDICAL CARE17H.COUNTY INSTITUTIONS18I.UNIVERSITY MEDICAL CENTERS19J.PLANNING AND EVALUATION20AUGUST 1977 SUPPLEMENTAL RECOMMENDATIONSSEPTEMBER 19, 1977 ADDENDUM13. 162224
STATE OF CALIFORNIAEDMUND G. BROWN JR., GovernorCOMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY11th & L BUILDING, SUITE 550, (916) 445-2125SACRAMENTO 95814ChlJirmllnNATHAN SHAPELLBeverly H 1sSeptember 1977Vlc.Ch"innllnDONALD G. LIVINGSTONLos AngelesALFRED E. ALOUISTSenator. San JoseMAURICE RENE CHEZLos AngelesDAVID P. DAWSONSan FranciscoJACK R. FENTONAssemblyman. MontebelloEDWARD M. FRYERPortola ValleyRICHARD D. HAYDENAssemblyman. CupertinoMILTON MARKSSenator, San FranciscoHonorable Edmund G. Brown, Jr.Governor, State of CaliforniaHonorable James R. MillsPresident pro Tempore, and to Members of the SenateHonorable Leo T. McCarthySpeaker, and to Members of the AssemblyMANNING J. POSTBeverly HillsLLOYD RIGLERLos AngelesALAN E. ROTHENBERGSan FranciscoCARMEN H. WARSCHAWLos AngelesL. H. HALCOMBExecutive DirectorThe Commission respectfully submits its supplementary report on theadministration of the Statels Medi-Cal Program. This report is thethird in a series of supplemental reports issued by this Commissionsince the release in January 1976 of the IIAdministration of StateHea 1th Programs. IIThe Commission received detailed written response and oral testimonyfrom departmental and Medi-Cal Division officials indicating almostfull agreement with the findings contained in our 1976 report. Untilrecently, however, the Division has not shown much interest in ourfindings nor has there been much tangible evidence of a plan toimplement our recommendations. Instead the Division has been overlypreoccupied with eligibility rules, rates and fees, program regulations,and treatment authorizations. It has paid far too little att ntion tothe needs for improving the organization of services, streamliningmethods of reimbursement, and increasing the access of low incomepatients to a comprehensive scope of services.The newly appointed Deputy Director in charge of the Medi-CalProgram has suggested that the Commission conduct a completelynew review of the Division operations, rather than to rely uponthe Divisionis previous written response, or upon the testimonypresented at two public hearings. In view of apparent sinceredesire to correct organizational and operational deficiencies, theCommission concurred with this request. Accordingly, the analysisand additional review was conducted in June and July of this year.We are pleased to report that this review led the Commission toconclude that under new leadership the Division is in the processof implementing ninety percent of the Commissionls recommendations.We believe that more conservative management, when fully implemented,should result in a ten to fifteen percent reduction in program costs.Based on current budget projections for Fiscal Year 1977-78, this
September 1977Page Twosaving will range from 300 to 450 million annually. This range ofsavings is only possible if the department pursues a vigorous programof enforcement against fraud and abuse and implements strong managementcontrols.The great potential for both savings and loss is demonstrated by therecent allegation of a Medi-Cal overrun of approximately 200 million.This Commission has warned of the catastrophic consequences which couldresult from the State's huge medical budget being out of control. Thesafeguards and management controls recommended will greatly aid thereduction of these types of problems and the great potential for loss.A well organized, efficient operation of the Medi-Cal Program has astrong impact on the operations of other health programs. The extensivenetwork of crossover funding may be more difficult to administerefficiently if the department is broken up into several separate andautonomous organization units.It is anticipated that a fourth and final supplemental report dealingwith the review of state hospital programs and community services forthe developmentally disabled will be released in October. In theFall of 1978, the Commission will review the progress that has beenmade in the provision of health services to the State of California.Accordingly, the Commission will schedule additional public hearingsat that time to assure that the intended program reforms have actuallybeen implemented.Donald G. Livingston, Vice ChairmanSenator Alfred E. AlquistMaurice Rene ChezDavid P. DawsonAssemblyman Jack R. FentonEdward M. FryerAssemblyman Richard D. HaydenSenator Milton MarksManning J. PostLloyd RiglerAlan E. RothenbergCarmen H. Warschaw
SUPPLEMENTARY REPORT ON THE ADMINISTRATIONOF THE STATE MEDI-CAL PROGRAMSEPTEMBER 1977I.NINETEEN MONTHS OF PROGRESS--AN OVERVIEWThe Commission issued its first report on the Medi-Cal Programin January 1976 as part of a report entitled, liThe Administrationof State Health Programs." The Connnission doncluded that thishuge program (budgeted for 2.6 billion in Fiscal 1975-76, andfor 3.1 billion in Fiscal 1977-78) could not be properlyadministered by the Department of Health or anyone else, dueto the obstacles to proper management which had become ingrainedin the program. The Commission recommended extensive, specificchanges to bring Medi-Cal under a semblance of managerial control.A written response was not made by the Department for one fullyear.Subsequently, the Commission held two public hearings:March 16, 1977 in Sacramento to hear testimony from representativesof the Department and the fiscal intermediary, and April 20 inLos Angeles to hear the comments of Medi-Cal providers and users.In opening the supplemental hearings, Commission Chairman NathanShapell noted the "alarming rate of growth" in the bud et forMedi-Cal, the largest human service in state government. Hesummarized the main points of the Commission's January 1976report: "A crisis of major proportion is imminent . an eligibilityprocess which is overly complex and expensive to administer .fiscal intermediaries whose system is totally inadequate fordetection of questionable provision of services . apparentwidespread fraud and abuse by private providers . prepaid healthplans under Medi-Cal have become a national embarassment forCalifornia, tainted with widespread scandal . county institutions,the traditional vehicle for public services for the poor, are facingcollapse . "At the March 16 hearing, representatives of the Department ofHealth and its Medi-Cal Division acknowledged many seriousshortcomings in the program.They described numerous stepswhich are being taken--many of them recommended by the Commission to bring Medi-Cal under tighter fiscal and administrative control.-1-
As Raymond Procunier, the Department's chief deputy director,put it: "There are going to be a lot of rocky roads, a lot ofproblems, but I think that together we can do it." Alsotestifying on details of the fiscal operations was the executivedirector of Medi-Cal Intermediary Operations, the private venturewhich has held the contract since the program began 11 years ago.Witnesses at the April 20 hearing included Medi-Cal providers,recipients, and organizations representing them. Theirtestimony in large part concerned the red-tape involved in theMedi-Cal treatment.The Department's written response and oral testimony indicatedalmost full agreement with the findings of the Commission, butlittle tangible evidence of a coherent plan to implement itsrecommendations.Shortly after completion of Commission hearings,a new Department deputy director was appointed to head theMedi-Cal Division. He suggested that the Commission conducta complete new review of the program, rather than base thissupplementary report entirely on the response of the Departmentand the hearing record. Such a review was carried out in Juneand July of 1977, consisting of extensive interviews with seniorstaff in the Medi-Cal Division, together with a study of currentpolicy statements and administrative practices.This review leads the Commission to conclude that, under newleadership, the division is in the process of implementing morethan 90 percent of the Commission's original recommendations.The division is ready to assume direct control of policy fordetermining criteria and standards for medical policy andmethods for review of these standards. Certain parts of theclaims processing system will be placed under direct controlof the department. Other information systems will be evisedto enable the department to evaluate the characteristics of theeligible population and to make comparisons in the patterns ofservices offered by a wide variety of providers.These policy initiatives are reflected in the development oftwo important "requests for proposals." One will revise theeligibility information file to increase its accuracy; thesecond will make fundamental revisions in the claims processingsystem and fiscal intermediary contract. These proposalsconcentrate on the accomplishment of eleven policy initiativeseither recommended or endorsed by the Commission:1) Simplification of standards, methods of determiningand recording of eligibility, and revision of the centralidentification to make daily updates through an on-line system.-2-
2) Studies of the eligible population with a goal ofreducing numbers of categories and awarding longer periods ofeligibility at lower administrative costs. The validity ofthese studies, however, depends on a more accurate eligibilityfile.3) Direct departmental control of standards and criteriafor Medi-Cal procedures and methods for reviewing performancein the claims processing system.Stronger on-site monitoringof fiscal intermediary operations. The criteria for review bythe Professional Standard Review Organization should be setby the Department.4) Initiation of a system of selecting providers throughcontracts which require adherence to professional standards,developed by the department with clinical consultation, as acondition of continued participation in Medi-Ca1.5) Preservation, in the competitive bid for a new fiscalintermediary contract, of the department's option to assume theclaims review and payment function entirely within five years.6) Computerized review of patterns of providing servicesto trigger more targeted audits, referrals of suspect providersto investigations for fraud, and enforcement against programabuse.7) Encouragement of testing new methods of reimbursement ona prospectively budgeted basis to organizations capable ofproviding a full range of comprehensive and continuous servicein a more organized fashion.Factors stressed are prevention,integrated primary ambulatory services, controlled referral tospecialized care, and planned reduction in unnecessary admissionsto hospitals and long-term care facilities.8) Adoption of a case management system for Medi-Ca1recipients whose condition requires prolonged and expensivelong-term care or rehabilitation.9) Systematic study of providing maximum benefits to theMedi-Ca1 population in order to reduce state costs by takingfull advantage of federal financial participation.10) Expansion of capitation contracts with organizationswhich have the potential to provide better organized, moreefficient, and hence less costly services.A high priority shouldbe assigned: to stronger and more equitable support-ofcounty institutions, reputable prepaid health plans, foundationsfor medical care, and university operated or affiliated countyhospitals.-3-
11) Development of an organized capacity within the Medi-CalDivision, devoted to program planning evaluation and policydevelopment. This unit would integrate systems of information,would inventory and refine reports to eliminate those ofquestionable validity or use, and would design and conductstudies of importance to the continuous refinement of managementpolicy. -4-
II .SUMMARY OF JANUARY 1.976 REPORTThe growth of the Medi-Cal Program has consistently exceededestimates. Its growth now threatens to financially encroachupon other essential state services.The Commission's 1976 report criticized Medi-Cal's excessiveadministrative costs, reported approaching 40 percent of thetotal program cost. The eligibility system for determiningwhether a person is eligible for Medi-Cal was found undulycomplex and expensive to administer. Although the staterequires the counties to provide medical services to theindigent, the definition of indigency varies from county tocounty so some counties are paying a disproportionate amountto erye indigent .Because the state Medi-Cal Division receives its basic eligibilitydata from various state, county and federal sources--oftenunverified for accuracy--the eligibility file is vulnerableto a large degree of error. This results in unwise use ofstate money by providing services to some who are not eligibleand denying care for others who are eligible. A severe scarcityof resources persists in low-income urban and rural communitiesdespite the staggering expenditures made over the past 10 yearsfor the care of the Medi-Cal eligible population.Lack of an accurate, up-to-date eligibility file also precludeseligibility and utilization analyses which are essential to goodmanagement. To add to the confusion, inconsistency was foundin eligibility standards for Medi-Cal and other health programsadministered by the Department. The report also addressed theneed for maximizing legitimate benefits for recipients hileeliminating services which are not medically necessary. Concernwas expressed over Medi-Cal's heavy use of hospital and otherlong-term care, and relatively little emphasis on preventiveservices. Providers of lesser integrity perform unnecessaryservices in an effort to make up for the rates which Medi-Calpays, widely declared to be too low.When the report was prepared, about 80 percent of the paymentsto providers were made on a fee-for-service basis at "reasonable"rates.However, the Department had not undertaken a costbenefit study of this method as compared to providing servicesthrough foundations for medical care, prepaid health plans,university hospitals or county institutions.The report noted that the prepaid health plans under Medi-Calhave been plagued by mismanagement; foundations have not provento be more cost-effective; university medical centers haveproblems uncompensated losses-and providing basic services, dueto their primary mission as teaching hospitals;-and the heavyfinancial burdens which the state placed on county hospitals-5-
forced some to close, and seriously eroded the quality ofcare which others provide to patients who have no otherresources.The data acquisition and processing system is largely controlledby the fiscal intermediaries who, in turn, are controlled byproviders. Defective information systems enable providers toabuse the program without detection. The Commission criticizedthe fragmentation of auditing, investigations and qualitycontrol among two state agencies and the fiscal intermediary,instead of having them all under the control of the Departmentof Health.Also cited was the notable lack of a formal planningand evaluation program within the Division.In summary, Medi-Cal has been overly preoccupied with eligibilityrules, rates and fees, program regulations, and treatmentauthorizations. At the same time it has paid far too littleattention to the need forimprovi?g the·organ1zation of 'services,streamlining methods of reimbursement, and increasing the accessof low-income patients to a comprehensive scope of services.* * *The Commission's complete, 420-page January 1976 report,entitled, "A Study of the Administration of State HealthPrograms," may be obtained by writing the Department ofGeneral Services, Publications Section, P. O. Box 1015,North Highlands, Ca., 95660, and enclosing a check or moneyorder for 6.00 payable to IIState of California, DocumentsSection."-6-
III .RE SPONSE TO RECOMMENDATIONSFollowing are the major recommendations of the Commission'sJanuary 1976 report on the Medi-Cal program (with pagereferences.) They are followed by an analysis of stepsthe Department has taken in response to those recommendations, as determined by Commission hearings and staffinvestigation.A.Administrative Costs"The Department of Health should commissiona study of administrative costs in Medi-Cal,taking into consideration the costsgenerated by the Administrative processeslisted in the findings of this report."(pg. 156)As yet, the Department has not seen fit to call upon outsideconsultants to perform an objective, pro essional assessmentof the administrative costs of the Medi-Cal program. However,in developing a proposal to call for bids for a new fiscalintermediary operations contract, there is a refreshingacknowledgement by the staf that improved informationsystems--and the department's assuming direct controlover some of them--holds the promise for ending wastefuladministration and uncontrolled provision of services. TheCommission will elaborate on the Medi-Cal intermediaryoperations procedurement project later in this report.B.Fees and Quality of Care"The Department should study alternative to its present vulnerability to payingfor the excesses which prevail in theprivate sector.A reduction in the numberof fee providers, expansion of qualityprepaid plans, expanded support to countyinstitutions, and preferential treatmentto Foundations or Medical Care couldsubstantially reduce cost and enhancequality of care." (pg. 157)"The principle of selection of providersshould be applied to the Medi-Cal programas is now done under Crippled ChildrenServices. The installation of aProfessional Standard Review Organizationcapacity in the Department of Healthwould enable the Department to identifypatterns of practice which are substandard-7-
and eliminate those providers fromparticipation. The quality reviewprocess should deal with all types ofproviders, individual and institutional.Reimbursements from Medi-Cal should beconditioned on a satisfactory reviewrecord.Incompetence and exploitationmust be added to fraud as grounds forremoval from the program." (pg. 158)' he Department, in its dealings withorganized providers, should move in thedirection of prospective budgeting andreimbursements, composite rate reimbursements and prepayment, and move away fromprocedural billing. The cost of processingfees for every service provided is highand inherently wasteful." (pg. 158)"The auditing and recovery functionsnow lodged in the Department of BenefitPayments should be transferred into theMedi-Cal Division in such a position thatboth functions articulate with the servicesreview operation, as described above andwith investigations." (pg. 161)Methods of reimbursement constitute a powerful tool for containingMedi-Cal costs.Every opportunity should be employed to reducethe program's vulnerability to fee-for-service reimburse
JACK R. FENTON Assemblyman. Montebello EDWARD M. FRYER Portola Valley RICHARD D. HAYDEN Assemblyman. Cupertino MILTON MARKS Senator, San Francisco MANNING J. POST Beverly Hills LLOYD RIGLER Los Angeles ALAN E. ROTHENBERG San Francisco CARMEN H. WARSCHAW Los Angeles L. H. HALCOMB Executive Director Honorable Edmund G. Brown, Jr.
Activity 3.5- "Sonnet 30" and “Sonnet 75” by Edmund Spenser Edmund Spenser 1. Meet Edmund Spenser 2. Participate in the large group discussion of "Sonnet 30" by Edmund Spenser. 3. Apply the strategies for reading poetry, and paraphrase the model poem. 4. Next, read and discuss "Sonnet 75" 5. Complete the graphic organizer 6.
Sonnet 30 Sonnet 75 Poetry by Edmund Spenser did you know? Edmund Spenser . . . worked as a servant to pay for his room and board at college. wrote a satire that was censored because it insulted Queen Elizabeth I and other English notables. Meet the Author Although Edmund Spenser was born in London and educated in England, he
DNA Project, Dr. Robert V Rice 12A Woodview Drive, Falmouth, MA 02540 (508) 548-4960 rvrbarre@verizon.net Director Emerita Ruth M. Brown EDMUND RICE (1638) ASSOCIATION NEWSLETTER Published winter, spring, summer and fall by the Edmund Rice (1638) Association
Edmund Spenser(1552 - 13 January 1599) Edmund Spenser was an English poet best known for The Faerie Queene, an epic poem and fantastical allegory celebrating the Tudor dynasty and Elizabeth I. He is recognised as one of the premier craftsmen of Modern English verse in its infancy, and one of the greatest poets in the English language. b Life /b
Edmund Landau studied mathematics in Berlin and Munich, and taught at Berlin University as a Privatdozent beginning in 1901. He married Marianne Ehrlich (1886- 1963) on 22 March 1905. The wealthy couple had two daughters. Both Edmund Landau's father and his father-in-law, the Nobel prize laureate (in 1908) Paul Ehrlich
EDMUND LANDAU G. H. HARDY and H. HEILBRONN*. Edmund Landau, an honorary member of this Society since 1924, was born in Berlin on 14 February 1877, and died there on 19 February 1938. He was the son of Professor Leopold Landau, a well-known gynaecologist. After passing through the "French Gymnasium" in Berlin, he entered
Chapter One: Edmund Blunden and his Undertone of the Great War 1.1. A Succinct Biography of Edmund Blunden In the first chapter of this dissertation, I will give a succinct biography of Edmund Blunden, because he is a great writer who, sadly and - as far as I can see, unjustly - has never received the appreciation and fame that he deserves.
2. When Lucy tells the others Edmund has also been to Narnia: a. Peter and Susan are overjoyed. b. Peter and Susan think they are both lying. c. Edmund denies it and says it was just a pretend _ game. d. Peter and Susan decide to go to Narnia right away. 3. Peter becomes: a. very angry with Edmund for encouraging Lucy. b. very angry with Lucy .
