While the Department has made efforts to ensure inmates are provided quality healthcare, it has not established adequate controls to ensure the healthcare is delivered cost-effectively. This lack of controls has resulted in a poor process for controlling access and payments to outside healthcare providers. Furthermore, the Department has had difficulty implementing legislative reforms designed to control costs.

A lack of adequate planning has also affected the Department's ability to develop and maintain a cost-effective inmate healthcare system. Although the Department has made attempts at planning, the plans have not always been fully implemented or updated. The Medical Division has not clearly defined its goals, objectives, or methods to measure performance. Not having these elements defined contributes to the Medical Division's inability to collect and maintain basic program information. This information is necessary for management to make informed decisions and determine whether programs are operating properly. In addition, issues such as the range of services to be provided and appropriate staffing levels have not been adequately clarified. 

• In fiscal year 1997 Nevada's average daily medical cost per inmate of $9.37 ranked as the fourth highest of the western states and eighth highest in the country. During the 10-year period ending with fiscal year 1997, the annual cost for providing healthcare increased 120 percent to nearly $3,400 per inmate. This increase is four times the rate that the total Department cost per inmate increased, excluding healthcare. (page 13)

 

• The Medical Division has poor controls for authorizing access to outside medical care. In 57 instances of the 110 inmate cases we reviewed, there was no evidence of prior DOP approval as required in Department policy. The Department spent nearly $5 million in outside medical care in fiscal year 1997. By failing to comply with its own financial controls and cost containment practices, the DOP cannot ensure all expenditures for outside medical care are necessary and appropriate. (page 17)

• The Department lacks an adequate system to ensure nearly $5 million in annual medical claims are processed accurately and appropriately by the third- party administrator. DOP staff review weekly lists of proposed payments; however, there are no written guidelines for staff to use to determine if payments are reasonable and appropriate prior to approving payment.

• The Department has had difficulty implementing legislative reforms designed to decrease unnecessary medical costs. These reforms include collecting co-payments for medical services, and reimbursements for injuries that are self-inflicted or the result of inmate-to-inmate violence or recreational activities. The Department's lack of an effective system for identifying eligible medical costs has hindered the collection of reimbursable charges. Although the Department has not routinely maintained information on reimbursable medical costs, it began implementing a process in fiscal year 1998 to better identify those costs eligible for recovery. For example, the DOP identified $474,000 of these medical costs for just the first six months of fiscal year 1998. However, during this same period only $16,500 had been collected. By April 30, 1998, collections had increased to $105,000. (page 24)

• Although the Medical Division spends millions of dollars each year, it does not use a strategic planning process to identify goals, objectives, strategies, and meaningful performance measures. Not providing clear guidance through a strategic planning process can result in a lack of direction within an organization and an inability to control costs. (page 27) 

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• The Prison Medical Division does not collect and maintain basic program information in a summarized and readily available format. Without this information Department management and external stakeholders cannot make informed decisions. In areas where more detailed activity and financial data are available, little is done to ensure the completeness and accuracy of the information before its use. Information not maintained includes historical data on staffing and expenditures in the categories of medical services, mental health services, dental, and pharmacy. Information on inmates' utilization of medical services and cost comparisons by institution is also not routinely maintained. (page 31)

• The DOP lacks adequate justification for its level of staffing to provide inmate mental health services. Moreover, external factors such as the Taylor v. Wolff lawsuit have driven the level of services provided rather than state goals and objectives. It is possible a constitutionally-acceptable range of services could be offered using fewer staff. If the Department chose to realign its staffing levels with the national average, more than $2 million annually may be freed up in deferred hiring of mental health staff when future prison facilities are opened. (page 34)

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1 Implement a comprehensive system of management
controls to provide an established level of care in
the most efficient manner..........................................                 X

2 Revise policies, procedures, and practices to ensure
outside medical care is only used when necessary
and properly authorized............................................                 X

3 Establish procedures to monitor payments made to
outside providers by the third-party administrator......                 X

4 Develop an effective system for identifying, charging,
and collecting all allowable medical costs..................                 X

5 Use a strategic planning process to develop goals,
objectives, strategies, and valid performance
measures for the Medical Division............................                 X

6 Identify and collect information needed to accurately
measure Medical Division performance....................                 X

7 Coordinate with DOP's Support Services Information
Systems Division to consolidate information from
the third-party administrator and the Nevada Cor-
rections Information System....................................                 X*

8 Evaluate the current range of mental health services
based on inmate need, identify the services neces-
sary to fulfill those needs, and determine the staffing
levels which will most efficiently deliver the services.                 X

TOTALS                                                                                 7                1