Gary C. Mohr, Director Ohio Department of Rehabilitation & Correction ASCA/CCHA Training September 11, 2014 P-PACA-Cost Containment The Ohio Experience My journey into becoming the Director of the Ohio Department of Rehabilitation and Correction (DRC). Appointed by Governor John Kasich in January 2011, I recently celebrated over 40-years of correctional experience. I start each day with the thought; “It’s a great day to be alive, as each day provides an opportunity to impact the future of tomorrow. With that in mind, DRC staff have dedicated their time and talents to implementing a multitude of strategies to reduce violence, establish stability and decrease recidivism. I am committed to maintaining and strengthening partnerships formed with Reentry Coalitions, Judicial Stakeholders, Faith- Based Community, as well as key players who take an active interest in the success of an offender’s reentry into society. ODRC is proud to national leader in offender recidivism with a record low of 27.1%. Gary C. Mohr, Director Ohio Department of Rehabilitation & Correction

The Ohio Experience ODRC Demographics Cost of Healthcare Services Patient Affordable Care Act & Medicaid Expansion ODRC Demographics Cost of Healthcare Services Cost Containment & Other Opportunities

Patient Protection Affordable Care Act & Medicaid Expansion P-PACA – Attempts to control rising healthcare costs Protect consumers Expand insurance coverage Shifts focus to wellness prevention Increase the healthcare workforce Serves as the platform for Medicaid expansion Governor Kasich’s (RP), passion and desire to help the most vulnerable citizens in our state has been the driving force of Ohio’s Medicaid expansion.

Current Status: Medicaid Expansion under PPACA – The Ohio Story Medicaid expansion under PPACA in Ohio has been a key initiative of Governor Kasich’s Office of Health Transformation (OHT) July 1, 2013 – DRC began activating Medicaid coverage for Hospitalized more than 24 hours Under 21 years old Over 65 years old Pregnant September 26, 2013 – Ohio’s Medicaid Director submitted a State Plan Amendment to extend Medicaid coverage to childless adults beyond traditional categories (pregnant, disabled, over 65, etc) October 21, 2013 – State Plan Amendment to extend Medicaid coverage approved by the Controlling Board, thus becoming effective January 1, 2014 – Governor Kasich authorized the expansion of Medicaid Services to all residents living within Ohio. We would not be here today without the passage of the Governor’s passage of the expansion of Medicaid Services to all Ohioans. Based on the expansion most offenders within ODRC will now qualify for Medicaid. Medicaid expansion broadened the categories of eligibility allowing most offenders within ODRC to now qualify. The DRC strongly believes that access to continuing treatment & healthcare services is critical to reentry efforts of Ohio offenders.

Patient Affordable Care Act & Medicaid Expansion DRC’s Office of Correctional Healthcare has partnered with the Ohio Department of Medicaid (ODM) for several reasons including: Assess the impact of Medicaid expansion on the state’s offender population. *Nearly every Ohio offender will be eligible for Medicaid Based on their financial eligibility upon release from incarceration. Achieve a shared goal of enrollment of every eligible offender into Medicaid 90 days prior to their release. Recidivism reduction by preparing offenders for successful transition back to the community after release from prison

Ohio Department of Rehabilitation & Correction – Agency Overview ODRC Operates independently of county jails and the Department of Youth Services Comprised of 27 facilities 25 state operated 2 privately owned Current Healthcare Model – State operated/controlled

ODRC Prison Population July 1 2011-July 1, 2014

Agency Demographics – Commitments by Age & Average Age Average Age of DRC Inmates: Male Inmates – 36 years old Female Inmates – 35 years old

Agency Demographics – Bureau of Medical Services 39% of the population is enrolled in a specialized Chronic Care Clinic Operate 325 high acuity medical beds Medical Needs: 20% of all inmates are on the mental health caseload Operate 500 Residential Treatment Unit beds for SMI inmates Mental Health Needs: 80% of all inmates have a history of substance abuse related issues 41% have a considerable (chronic) need for treatment Recovery Service Needs of Inmates entering ODRC:

Agency Demographics – Offender Costs This graph supports our agency as a whole has decreased overall costs per offender while continuing to provide for their daily needs in a manner In 2009, Ohio Prison’s healthcare expenditures reached a peak of 292 million dollars. Over the past four years while general health care cost have increased throughout the country and while we were in litigation for providing inadequate health care; we were able to decrease our health care cost by 54 million dollars while increasing the quality of health care and life longevity of an inmate.   The Department of Rehabilitation and Corrections is anticipating a savings of over 18 million a year due to Medicaid paying for a 24 hour or more in-patient hospital stay; this allows us to reinvest money into other evidenced based programs, which will help incarcerated and offenders within the community.

ODRC Healthcare Cost Comparison Annual Cost Per Inmate Stu Hudson, Managing Director of Healthcare and Fiscal Operations is going to share how we have made cost reductions while increasing quality medical care and optimizing staffing levels. Our agency has reduced our annual healthcare cost by $54 million since 2009.

Maximizing Correctional Healthcare Quality with Strategic Business Planning The Ohio Experience Stuart Hudson, Managing Director of Healthcare & Fiscal Operations Office of Correctional Healthcare Ohio Department of Rehabilitation & Correction

Correctional Healthcare Reality Today Increase in aging offenders & associated chronic disease burden Rising pharmaceutical costs (Sovaldi, HIV meds, etc.) Continuous scrutiny from stakeholders Legal liability (deliberate indifference and/or mal-practice) And…… Decreased or tight funding that impacts correctional healthcare

ODRC Medical Spend Past Decade Fussell Stipulation beginning 2006, ending 2012 Staffing higher now than during stipulation, while costs are lower

Diverse Business Strategy to Maintain Quality and Efficiency Managed Care - Bill re-pricing - Collegial Review - Data analysis & reporting - Evidence based medicine - Medicaid Impact - Metrics Insourcing - Advanced Level Providers - 2 Privatized facilities Outsourcing - Lab services - Allied Health - Dietary State Agency Partnerships - Pharmacy - Medical supplies - Lab contract - EHR Other - OSUMC - Contract simplification - CT-MRI-PET - Urgent Care - Contract compliance Managed Care: Pre Medicaid: Billing retrospective reviews, Pre-certification of specialty consultation, 3rd party case management of in-patient stays Post Medicaid: Bill re-pricing by 3rd party, Collegial Review, Permedion – billing data analysis, surveillance, & reporting, Medicaid Impact In-Sourcing: Advanced Level Provider (ALP) Services: This change was key to exiting Fussell Stipulation, ODRC spend was less in FY14 than in FY08 with more ALPs in a civil servant system (11.8 vs. 11.3 million for savings of .5 million Converted Private Healthcare Services to Civil Servant: Affected 2 facilities, Savings of approximately 1million per facility Out-Sourcing: Lab Services - Closed internal COLA accredited lab, Multi-agency RFP, LabCorp is provider, Maintained quality, increased savings & efficiency Allied Health Services - Includes HITs, Phlebotomists, Radiology techs, aides Dietary Services - Transitioned from civil servant diet techs to contract, Services part of overall foodservice RFP, Menu and clinical protocols controlled by ODRC State Agency Partnerships: Pharmacy and Medical Supplies – ODMHAS (Current costs are at $29.7 million for FY14. They were $30.8 million in 2008 – and we have more CCC patients and higher acuity now), Lab – multi-agency bid for increased volume / decreased pricing, EHR – DYS Other /Miscellaneous: OSUMC contract decreased by 10 million Contract simplification – reduced contracts from 375 in 2010 to 65 currently – easier to manage CT-MRI-PET – Purchased or leased in house , decreased costs and easier scheduling – secure Urgent Care – off hours UC services to decrease ER trips and costs, minor procedures / sutures, secure Contract Compliance – division at central level, all contracts monitored for quality, multiple options for handling non-compliance or need for improvement – leads to stability and accountability

Ohio Department of Rehabilitation & Correction - One Patient, One Team In-sourcing: Advanced Level Provider (ALP) Services: Civil servant ALPs invested in leadership / long-term success This change was key to exiting Fussell Stipulation ODRC spend was less in FY14 than in FY08 with more ALPs in a civil servant system (11.8 vs. 11.3 million for savings of .5 million) Increased utilization of NPs for ALP coverage Converted Private Healthcare Services to Civil Servant: Affected 2 facilities Savings of approximately 1million per facility Ohio Department of Rehabilitation & Correction - One Patient, One Team

Ohio Department of Rehabilitation & Correction - One Patient, One Team Out-Sourcing: Lab Services - Closed internal COLA accredited lab - Multi-agency RFP, LabCorp is provider - Maintained quality, increased savings & efficiency Allied Health Services - Includes HITs, Phlebotomists, Radiology techs, aides - Significant savings while maintaining quality - Prioritization of lead clinical staff (nursing, ALPs) Dietary Services - Transitioned from civil servant diet techs to contract - Services part of overall foodservice RFP - Menu and clinical protocols controlled by ODRC Ohio Department of Rehabilitation & Correction - One Patient, One Team

Partnership with other State Agencies Pharmacy Partnership with the Ohio Department of Mental Health & Addiction Services Medical Supplies Lab Multi-agency bid to increase volume / lower pricing Electronic Health Record Other state agencies joining the ODRC contract (DYS) Pharmacy – ODMHAS (Current costs are at $29.7 million for FY14. They were $30.8 million in 2008 – and we have more CCC patients and higher acuity now) Medical Supplies – ODMHAS (Current costs are at $1.3 million for FY14. They were $2.2 million in FY2010 Ohio Department of Rehabilitation & Correction - One Patient, One Team

Contract Simplification Ohio State University Medical Center Other Strategies: Contracts reduced from 375 in 2010 to 65 currently Contract Simplification Purchased / leased equipment for these diagnostics to be done in house. Greater control over scheduling at reduced cost PET-CT-MRI ODRC operates UC during off hours Prevents some ER trips for things like sutures & minor procedures Keeps inmate patients within ODRC security Urgent Care Reduced overall contract costs by $10million/year last contract Ohio State University Medical Center ODRC maintains a contract compliance division at the central level All contracts are routinely monitored for compliance / quality Multiple options to improve compliance or handle non-compliance Contract Compliance Ohio Department of Rehabilitation & Correction - One Patient, One Team

Results of Strategy The value of people – Clinical staffing is at an all-time high Quality is maintained/enhanced Reduced legal liability Costs are contained Business is manageable ODRC is positioned for the future Medicaid moving forward EHR moving forward Tie into overall core values and mission/vision Medicaid impact certainly impacts our mission and vision Future concerns and considerations: Impact of Sovaldi Ability to get 340B Ongoing impact of Medicaid on budgets

Questions? Future concerns and considerations: Impact of Sovaldi Ability to get 340B Ongoing impact of Medicaid on budgets