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

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

Statement

District of Columbia Receivership: Selected

Issues Related to Medical Services at the D.C.

Jail

Page 1 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

 

1

 The term “medical services” will be used in the remainder of the testimony to refer to both medical

and mental health services.
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 2 GAO/T-GGD-00-173

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:

• 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.

• 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.
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 3 GAO/T-GGD-00-173

• 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.

• 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.

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

 

2

 See Campbell v. McGruder, C.A. No. 14 62-71 (D.D.C.).

Background
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 4 GAO/T-GGD-00-173

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.

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.

 

3

 See Inmates of D.C. Jail v. Jackson, C.A. No. 75-1668 (D.D.C).

D.C. Jail Medical Costs

Higher than Other

Jurisdictions, But

Caution Needed in

Interpreting

Differences
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 5 GAO/T-GGD-00-173

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

 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.
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 6 GAO/T-GGD-00-173

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 notfor-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

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

 

5

 429 U.S. 97 (1976).

No Single Threshold

Defines Acceptable

Levels of Medical

Service and Staffing
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 7 GAO/T-GGD-00-173

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.

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

 

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.

Possibilities Exist to

Reduce Future

Contract Costs
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 8 GAO/T-GGD-00-173

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.

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.

Receiver Employees

Were Not Subject to

D.C. Personnel

Regulations
Statement

District of Columbia: Contracting for Medical Services at the D.C. Jail

Page 9 GAO/T-GGD-00-173

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.

Contacts and

Acknowledgements
Page 10 GAO/T-GGD-00-173
Page 11 GAO/T-GGD-00-173
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