Special Examination y 07-06

Why we did this review
In 2004, we issued a Program
Evaluation entitled “Inmate Health
Care” which evaluated the adequacy of
care provided to inmates housed in
Georgia Department of Corrections’
(GDC) facilities. Typically, we
perform a Follow-Up Review after
approximately two years to provide an
update on corrective actions taken by
the agency. Based on the scope of the
original report and our determination
that significant changes have occurred
within the GDC Health Program, this
Special Examination was performed in
place of a Follow-Up Review. A copy
of the 2004 Program Evaluation report
can be obtained through the contact
information provided on the last page
of this report.

Who we are
The Performance Audit Operations
Division was established in 1971 to
conduct in-depth reviews of state
programs. The purpose of these
reviews is to determine if programs
are meeting their goals and objectives;
provide measurements of program
results and effectiveness; identify
other means of meeting goals; evaluate
the efficiency of resource allocation;
and assess compliance with laws and
regulations.
Website: www.audits.state.ga.us
Phone: 404-657-5220
Fax: 404-656-7535

August 2007

Inmate Health Care
Inadequate staffing of central office
positions in the Department of
Corrections’ Office of Health Services
and of health care positions in the
Department’s correctional facilities has
adversely impacted the system of health
care provided to inmates.
What we found
In our 2004 Program Evaluation of Inmate Health Care, we
found that the Office of Health Services (OHS) within the
Georgia Department of Corrections (GDC) had “developed an
extensive management control system to effectively manage all
aspects of physical, mental, and dental health care.” Although
we recognized that problems were bound to exist in such a
complex system, we concluded that “the quality of the inmate
health care system is threatened by decreasing staffing levels
that are a result of budget constraints.” Other findings and
recommended corrective actions were also presented.
Our re-examination of the Inmate Health Care Program within
GDC found there has been a significant decrease in the size of
the central office staff in OHS, which is responsible for ensuring
inmates are provided the required constitutional level of care.
As a result, many of the controls previously in place, such as
conducting clinical audits, performing executive mortality
reviews, and addressing recommendations from correctional
health care experts, have deteriorated considerably.
Furthermore, the inmate population growth from fiscal years
2005 to 2007 has outpaced the budgeted staff in GDC facilities
who provide direct care services to inmates. Consequently, it is
increasingly difficult for GDC to ensure it is providing the
required constitutional level of care. The additional strain

placed on staff resources may increase the probability of experiencing bad health
care outcomes, and in turn, present increased risk of lawsuits against GDC.
Our review also found that total health care costs have increased at a faster rate than
in previous years, driven primarily by an increase in catastrophic inmate health cases.
GDC health care costs for fiscal year 2011 are projected to total $278 million, which is
approximately $99 million more than the $179 million expended in fiscal year 2006.
In its written response to the report, GDC noted that “While the Office of Health Services
does not challenge the data reported by the Department of Audits and Accounts we do, however,
interpret the data a bit differently. As with any organization, improvement can be made by and in the
Office of Health Services. The partnerships with our private and public healthcare partners are on
solid ground and progress is being made through the maturization of these relationships. We
appreciate the Department of Audits’ Report and always welcome a third party look at our
operations.”

Inmate Health Care

i

Table of Contents
Background
Examination Purpose

1

Purpose of Inmate Health Care

1

Inmate Health Care Rights, Standards, and Delivery System

1

Scope and Methodology

2

Analysis of Management Control System
Reduction of OHS Central Office Staff

2

Clinical Audits

4

Mortality Reviews

5

Recommendations of Health Care Experts

6

Use of Health Care Indicators

7

Utilization Management Backlog

8

Increased Risk in Dental Care

9

Analysis of Facility Health Care Staffing
Physical Care Staff

10

Mental Care Staff

11

Dental Care Staff

12

Analysis of Correctional Health Care Costs
Health Care Cost Projection

13

Decrease in Infirmary Beds

13

Other States’ Costs

14

Cost Containment Efforts

14

Competitiveness of GCHC Discount Rates

15

Outsourcing Physical Care Service Contract

15

Appendix: Health Care Staff, FY 2005 and FY 2007

17

Inmate Health Care

ii

Background
Examination Purpose
The purpose of this examination was to determine if the management control system
of GDC’s Office of Health Services (OHS) was adequate to effectively manage the
physical, mental, and dental health care provided to inmates. The OHS management
control system was initially evaluated in our 2004 Program Evaluation in which we
found that OHS had “developed an extensive management control system to
effectively manage all aspects of physical, mental, and dental health care.” In
addition to reviewing the current management control system, we updated our
projected correctional health care costs through 2011.

Purpose of Inmate Health Care
Inmates in the custody of either state, federal, or local correctional systems are
entitled to a constitutionally required level of health care. OHS’s purpose is to
ensure adequate health care is provided to Georgia’s state inmates in the most
efficient, cost-effective, and humane manner possible, while protecting the public
health and safety of the rest of the state’s citizens.

Inmate Health Care Rights, Standards, and Delivery System
Generally, courts have held that inmates have a right to reasonable health care
designed to meet their routine and emergency medical needs. Most notably, in Estelle
v. Gamble (1976), the U.S. Supreme Court found that an inmate has the right to be free
of “deliberate indifference to their serious health care needs” and that indifference is
a violation of a person’s Eighth Amendment protection against cruel and unusual
punishment.
While inmates are not guaranteed the right to the best health care available, an
accepted policy in correctional health care programs is to provide inmates with a
community standard of care, which may be defined in published recommendations
by expert panels or organizations (such as the Centers for Disease Control and
Prevention and the American Heart Association). Correctional health care programs
may also use standards developed by the National Commission on Correctional
Health Care and the American Correctional Association. GDC has defined its
standard of care through Standard Operating Procedures (SOP) as well as a
“Summary of Health Care Benefits.”
Health care in GDC facilities is provided by a combination of three organizations:
•

GDC’s OHS is responsible for providing clinical and administrative
oversight of care, managing the health care budget, determining staffing
levels, and monitoring vendors. GDC-employed health care staff primarily
include mental health counselors and dental staff (as shown in the
Appendix).

•

Georgia Correctional HealthCare (GCHC), a division of the Medical
College of Georgia, manages physical health care operations in GDC

facilities and also negotiates and manages contracts with providers of health
services (e.g., hospitals, specialty clinics, ambulance services, etc.) that
cannot be provided within GDC facilities. GCHC employs the physicians,
clinical practitioners, and most of the nurses.
•

MHM Services, Inc. (MHM) is a health care staffing agency utilized
primarily to employ psychiatrists, psychologists, and mental health
counselors.

Scope and Methodology
The scope of this examination was based primarily on the information presented in
the 2004 Program Evaluation report (entitled “Inmate Health Care”) with additional
topics covered as appropriate. The methodology included interviews with GDC and
GCHC personnel and reviews of program documentation.
This report has been discussed with appropriate personnel in GDC and GCHC. A
draft copy of the report was provided for GDC’s review and they were invited to
provide a written response, including any areas in which they plan to take corrective
action. Pertinent sections from GDC’s response have been included in the report as
appropriate.

Analysis of Management Control System
The significant reduction of OHS central office staff is adversely impacting
OHS’s ability to effectively manage all aspects of physical, mental, and dental
health care.
Our review found that OHS central office staff decreased from 29.5 budgeted fulltime equivalent (FTE) positions in 2004 to 13 FTEs in 2007. (Note: this does not
include 5.5 positions in the Utilization “Because litigation is so expensive, all
Management (UM) function which were efforts should be made to achieve
brought in-house in 2006; UM was voluntary compliance with national
previously operated by MHM.) The OHS standards of care and gain accreditation.
Facilities that meet community standards
organizational chart presented in Exhibit 1 of care are much less likely to face class
on the following page illustrates the action or even individual lawsuits.”
positions that were eliminated, those that Source: Guidelines for the Management of an
Delivery System by the National
still exist, and those that have been created Adequate
Institute of Corrections (2001).
since the 2004 evaluation.
The loss of the positions illustrated in the organization chart, as well as turnover in
key OHS leadership positions and loss of institutional knowledge, has diminished
OHS’s “extensive management control system” that was in place in 2004. It should
be noted some key positions have turned over more than once since 2004. The
diminished management control system regarding physical, mental, and dental care
is discussed in the following sections.

Contract Specialist

Admin Operations
Coordinator I

Admin Operations
Coordinator II

Assistant Health
Services Administrator

Secretary
Principal

Clinical Program
Consultant

Data Entry
Clerk
.5 FTE

Data Entry
Clerk

Clinical Program
Consultant

Source: GDC records, Staff interviews

Physician4,5
.5 FTE

Pre Release
Coordinator

Statewide Public
Health Coordinator

Clinical Program
Consultant

Program
Development
Consultant

UM Nurse
Manager4

UM Nurse4

UM Nurse4

UM Nurse4

UM Nurse4

Statewide Medical
Director

Statewide Clinical
Systems manager

Statewide Clinical
Supervisor

Secretary III

Health Care Concerns
Coordinator

Health Services
Administrator

Physical Care

Notes:
1. All positions represent a full-time equivalent (FTE) unless otherwise noted.
2. The OHS Director position has turned over twice since FY 2005.
3. The Statewide Dental Supervisor spends half of his time providing care to inmates.
4. The Utilization Management (UM) function was performed by MHM in FY 2005.
5. The UM Physician spends half of his time performing duties for GCHC.

Statewide Dental
Supervisor3
.5 FTE

Dental Care

OHS Director2

Exhibit 1
OHS Organization Chart1

Same Position

Secretary II

Secretary II

Clinical Services
Manager

MH Program
Development
Consultant

MH Program
Development
Consultant

MH Program
Development
Consultant

MH Program
Development
Consultant

Chief
Psychiatrist
.5 FTE

Statewide MH/MR
Program Supervisor

Previously Contracted Position

Currently Unfilled Position

MH Program
Development
Consultant

MH Auditor/
Re Entry
Coordinator

MH Program
Coordinator

Added Position
Deleted Position

Administrative
Secretary

Assistant
Statewide MH/MR
Supervisor

Mental Care

Legend
Same Position with turnover

In its response to this finding, GDC wrote the following:
“In the Office of Health Services (OHS)…it was my belief that we had a number of redundant
auditing and assessment processes in place. I [GDC Commissioner] directed that staff cuts be made
to the OHS with the clear intent of monitoring our performance in managing our health care
partners. If and when we determined that additional staff or resources needed to be returned to the
OHS, these additions would be addressed based on the appropriate justification. After having our
mental health program, physical health program, and general healthcare delivery system audited in
CY 2007, it became apparent that some positions needed to be added back to OHS. As you found, I
have authorized those changes in the staffing of OHS that I believe necessary to carry on the high
level of service for which this Agency is known.
I have authorized the hiring of two additional mental health program managers, an assistant
director, a part time physician, and a business analyst to complement the staff in OHS. I expect that
these additions to our team will be sufficient to address the concerns that the Department of Audits
and our Clinical Consultants have expressed.”

The frequency of physical health auditing conducted by GDC in state prisons
has not improved and GDC no longer conducts physical health audits at
probation detention centers or county correctional institutions. Additionally,
OHS no longer manages the auditing process and is less involved in monitoring
the results of these audits.
In 2004, OHS scheduled and managed health services audits at state prisons, probation detention
centers, and other GDC facilities. In its response to the 2004 Evaluation, GDC agreed with the
recommendation that auditing should occur more frequently and stated its intention to return to
annual auditing. It also added that “the OHS audit methodology was born out of past litigation.”
Our review found that GDC has not established an annual auditing schedule for
state prisons as it indicated in the 2004 Evaluation. Currently, GDC conducts
comprehensive audits1 approximately once every two years for state prisons, which
is the same frequency with which they were conducted in calendar years 2000
through 2003. We also found that GDC no longer evaluates physical health services
in probation detention centers or in county correctional institutions.
Our review also found that OHS no longer “Quality assurance has been defined as a
has the authority to schedule audits of ‘process of ongoing monitoring and
to assess the adequacy and
physical care as was the case in 2004. This evaluation
appropriateness of the care provided and
function is now coordinated by the GDC to institute corrective action as needed’…It
Office of Investigation and Compliance is an essential aspect of any well-run
(OIC). Furthermore, since OHS no longer system….”
Guidelines for the Management of an
employs a Statewide Clinical Supervisor or Source:
Adequate Delivery System by the National
subordinate staff (see the organization chart Institute of Corrections (2001).
on the previous page), which previously
oversaw the auditing function, OHS is less involved in monitoring findings and
1

Clinical audits of the physical health care provided in state prisons are currently conducted
as part of a larger “comprehensive audit” which also includes the evaluation of other facility
operations, such as security and personnel.

corrective actions related to physical health services. Interviews with current OHS
staff stated they may not be aware of issues arising from a clinical audit and that
there is no process to ensure they receive copies of all audit reports.
In its response to this finding, GDC wrote the following:
“The management philosophy of the Office of Health Services has transformed since 2004. It was
decided to transfer primary responsibility for the conducting of audits to GDC’s healthcare partners,
GCHC and MHM. GDC staff continue to be involved in conducting the audits, but the scheduling
and reporting of the audit findings is now a responsibility of our healthcare partners. GDC
continues to oversee the corrective action plans. The report is correct in stating that GDC does not
conduct regular audits of probation detention centers, county correctional facilities, and private
prisons. GDC’s Office of Investigations and Compliance schedules an annual comprehensive audit of
each of the state prisons. These audits include healthcare audits. In addition, our healthcare
partners schedule an additional audit each year of each state prison. Corrective action plans are
developed and monitored by GCHC, MHM, and GDC.”

OHS does not perform executive mortality reviews of inmate deaths and is
unable to locate medical files for many deceased inmates.
At the time of our 2004 evaluation, OHS conducted, as part of its extensive management control
system, Executive Mortality Reviews of inmate death cases “to ascertain the housing facilities’
compliance with OHS standards of care.” We also noted that the mortality review process was used
“to educate health care staff about trends in and causes of inmate deaths, and to correct any
identified deficiencies that may have contributed to the death.”
Our review of OHS files for inmate death records for calendar years 2005 and 2006
revealed that only 30 of 233 deaths (excluding executions) had evidence that OHS
clinical staff performed a mortality review. OHS explained that they ceased doing
on-the-record mortality reviews in late 2005 because of a court case in the 9th U.S.
Circuit Court of Appeals (West Coast) that potentially jeopardized the confidential
nature of these reviews. It should be noted, however, that only one of the 30 cases
which were reviewed occurred after the departure of prior OHS leadership staff,
suggesting that OHS staff turnover may also have contributed to the discontinuation
of the executive mortality review process.
Our review also found OHS was unable to “Maintenance of medical records is ‘a
locate files for 86 of the 203 deaths not necessity’ (Johnson-El v. Schoemehl,
reviewed. While OHS staff was unable to 1989), and numerous courts have
condemned the failure to maintain an
locate these files, staff stated they were organized and complete system of health
continuing to search for them, including care records.”
making contact with GDC facilities to Source: Guidelines for the Management of an
Delivery System by the National
determine if these files were still at the Adequate
Institute of Corrections (2001).
inmate’s home facility at the time of death.
According to GDC’s SOP, the home facility is responsible for completing its own
mortality review within 15 working days of the death and for submitting necessary
health records to OHS within 20 working days.
OHS and GDC Legal Services do not disagree that executive mortality reviews are
valuable. Although an Executive Mortality Review Committee was re-established in

May 2006 and OHS drafted new procedures for performing these reviews, the
process had not been re-started as of the time of our evaluation.
In its response to this finding, GDC wrote the following:
“A Federal Court ruling in 2005 declared physician peer reviews regarding inmate deaths to be
discoverable in litigation. This is the only type of medical peer reviews to be so declared. Written
peer reviews were temporarily discontinued. The report correctly states that 86 of 203 files on
deceased inmates could not be located at the time of the audit. In his annual report, [GDC’s physical
health care consultant] reported that OHS was indeed behind in conducting peer mortality reviews.
He recommended that ‘(GDC) continue with a process that includes a local death review…and then
that death review along with a copy of the (inmate) record should be available for a review by an
external reviewer.’ Approval has been granted to contract with an external reviewer for the purpose
of mortality reviews. To date, 41 of the 86 misplaced files have been located. Concerted efforts are
underway to locate the remaining files. A system has been developed to identify, track, and locate
files of deceased inmates.”

Recommendations made by nationally-recognized correctional health care
experts have not been sufficiently addressed.
In 2004, we commended OHS for annually contracting with correctional health care experts in both
mental health care and physical health care. We also determined that the expert recommendations
were given “serious consideration by OHS and [were] actively addressed.”
Although GDC continues to hire correctional health care experts to perform annual
evaluations of physical and mental care, we found that some of the significant and
persistent problems have not been sufficiently addressed and may continue to
deteriorate.
Physical Care Evaluations
At the time of our review, the last complete evaluation of physical health care was
performed in July 2006. The report summarizing findings on the status of physical
health care noted the following areas:
•

Mortality Review: The evaluator specifically noted the need for OHS to
review the medical files and documentation of the mortality review
performed at the inmate’s home facility.

•

Health Care Grievances: The evaluator found that 0 of 150 health grievances
filed by inmates and reviewed by the inmate facility in a two-month period
were found to be valid. In such cases, the evaluator concluded, “one has to
suspect that the method of determining validity may in fact be biased.”

•

Concerns over OHS turnover: “Virtually all of the leadership people who I
[the evaluator] met with during my June 2005 visit have either retired or
moved on. Prior to my arrival this clearly raised some concerns for me.”

•

Workload of the Statewide Medical Director: “I am particularly concerned
about the multiple responsibilities that [the Statewide Medical Director]

must now acquit. These include her large UM responsibilities as well as the
medical director role, which includes participating in audits at least two
weeks a month” as well as managing clinical policies and standard operating
procedures, handling medical reprieves, working with inmate families,
providing clinical training and other duties.
Mental Care Evaluations
The evaluations of mental care over the last four years have addressed staffing
problems which appear to be getting worse. The 2004 summary report cited
inadequate mental health staffing as a “major issue.” The follow-up in 2005 further
cautioned that “these problems remain as previously described, which has had a
significant negative impact on the mental health services being provided to many
GDC inmates.” The 2006 and 2007 reports repeat this finding that no significant
change had taken place. In 2007, the evaluator concluded:
“the operation of the mental health department…remains very
hampered by decreasing staff allocations and vacancies as previously
summarized. The ability of the central office to identify, and
generally fix, problems identified via the [continuous quality
improvement] process has continued to decrease for reasons that
include decreased and limited central office staffing allocations, lack
of an adequate management information system at the present time,
and the staffing allocation issues in the field as described elsewhere
in this report.”
In its response to this finding, GDC wrote the following:
“While all recommendations of our consultants are given attention, due to budget and staffing
limitations, all recommendations cannot be implemented. Considerable credibility is given to the
recommendations of our consultants and attempts are made to adopt and implement their
recommendations each and every year.”

GDC does not analyze health care audit scores and grievance data to review and
manage the delivery of health care.
In 2004, we recommended that OHS should analyze data on health care quality indicators to more
effectively manage the delivery of health care. In general, GDC agreed with this recommendation
and also added, “OHS will pursue the development of a plan to track and report all risk management
indicators to appropriate personnel in the interest of strengthening OHS oversight of inmate health
care delivery.”
Our review has determined that no plan to track risk management indicators has
been developed. Although GDC collects information on various aspects of health
care operations, the information is not used to assess the quality of care being
provided. For example, GDC comprehensive audits and GCHC regional reviews
generate audit scores on various aspects of a facility’s physical health care operations.
OHS does not utilize these audit scores to identify patterns or trends in the physical
care provided.
Similarly, although OIC enters inmate grievances into GDCs Offender Tracking
Information System (OTIS), neither OIC nor OHS generates reports from OTIS to

identify patterns in grievances related to physical, mental, or dental health. Also,
based on our review of 2006 data, there was a significant difference between the
number of grievances entered into OTIS by OIC and the number of grievances which
OHS had a record of receiving.
In its response to this finding, GDC wrote the following:
“Through GDC’s Office of Information Technology, a mental health module to our SCRIBE
operating system has been developed that will collect risk management, performance management,
and outcome data in our mental health program. Through our Third Party Administrator, OHS
receives data regularly that is being analyzed for risk management utilization… While the report is
correct in stating that we currently do not have information to assess the quality of care, we do have
a plan for developing that data and are assessing the quality of care via audits. In June 2007 the
responsibility for managing inmate healthcare grievances was assumed by the Office of Health
Services. More attention is being directed to grievances now than in the past.”

The backlog of Utilization Management (UM) requests and appointments
pending have increased.
In the 2004 report, we noted that many of the inmate appointments needed with medical specialists
occurred outside of GDC’s established timeframes.
Utilization Management (UM) is a cost-containment function utilized by GDC to
ensure that specialty appointments for various inmate health services are
appropriate and necessary.2 Requests for specialty services are sent to the UM staff
and reviewed for appropriateness based on applicable SOPs. Inmates whose
requests are approved are subsequently scheduled for an appointment with a
provider.
From our review of recent UM data, it appears there is a growing backlog of requests
pending review by UM staff nurses, as well as an increasing number of approved
requests (appointments) that have yet to occur, as shown by Exhibit 2 on the next
page.

2

UM was previously operated by MHM staff; GDC brought this function into OHS in
January 2006.

OHS staff stated they were aware of the increasing backlog and explained that
turnover in health care staff and continuing changes in the network of outside health
care providers used by GCHC were contributing to the difficulty in scheduling
appointments. OHS has also proposed changes to the UM SOPs, including the
timeframes within which appointments must take place, but these had not been
approved. An additional physician was also recently hired to assist the UM function.
In its response to this finding, GDC wrote the following:
“As with other areas, staffing for UM has not increased at the same level as the inmate population.
Not only has the number of inmates increased, the average age of the inmate population as well as the
inmates’ average length of stay has increased, resulting in more healthcare problems needing
treatment. A business process evaluation of the UM system is being planned for FY 08.”

Risk may be increasing in Dental Care.
Our interviews with OHS staff indicated that dental health was an area of significant
risk to GDC. The risk factors include the lack of dental staff in GDC facilities, the
vacancy of the Statewide Dental Supervisor position for approximately two years,
and the lack of dental auditing being performed during this period. Although,
nationally, inmate litigation in dental health has not been successful, it may only take
one successful case to increase the risk of litigation to GDC.

Analysis of Facility Health Care Staffing
Our 2004 report concluded that the “quality of the inmate health care system is threatened by
decreased staffing levels that are a result of budget constraints.” GDC agreed with this conclusion
and wrote in its response, “Staffing of health services within correctional institutions is becoming
increasingly difficult to maintain” and that “expenditures for maintaining an adequate health care
workforce within GDC will increase over the coming years, but will be necessary to deliver the
required level of care.”
Our review of health care staffing in GDC
facilities found an overall increase of
approximately 3% from fiscal year 2005 to
fiscal year 2007 as shown in Exhibit 3
below. During this period, however, the
inmate population in GDC facilities
increased by approximately 10%, resulting
in the ratio of inmates to total health care
staff increasing. Staffing related to
physical, mental and dental care areas is
discussed in more detail in the following
sections.

“Most cases in which courts have found
constitutional violations of inmates’ rights to
health care were fostered by the demands
made on an overburdened staff coping with
too few resources. No amount of concern or
good faith effort by medical staff can
overcome inadequate financing, and it is
perhaps in this area that the courts have
made their greatest contribution by
prompting and, if necessary, forcing
governmental decision makers to
appropriate the funds necessary to maintain
humane health care.”
Source: Guidelines for the Management of an
Adequate Delivery System by the National
Institute of Corrections (2001).

Exhibit 3
Budgeted Staffing in GDC Facilities (FTEs)

Physical Care
Mental Care
Dental Care
Other
Total

Fiscal Year
2005
2007
1,031.10 1,065.00
356.45
395.10
57.00
57.75
61.50
36.00
1,506.05 1,553.85

Change
#
%
33.90
3.3%
38.65
10.6%
0.75
1.3%
-25.50
-37.6%
47.80
3.2%

Source: GDC Staffing Plans

Physical Care Staff
Although the physical care staff increased by 3.3% as shown in Exhibit 3, much of
this increase was due to additional “support” personnel (see the Appendix for more
detail on staffing changes). Isolating the “direct” physical care FTEs (physicians,
clinical practitioners, and physical care nurses) indicates an increase of only 3.2 FTEs
as shown in Exhibit 4 on the following page. Relative to the increase in inmates
over this period, there are approximately five more inmates per “direct” care position
than were budgeted for in fiscal year 2005, a 9.8% increase in two years.

Exhibit 4
Budgeted Direct Physical Care Staff (FTEs)

Physicians
Clinical Practicioners
Nurses
Total Direct Care Staff

Fiscal Year
2005
2007
51.70
49.40
52.15
56.95
695.25 695.95
799.10 802.30

Change
#
%
-2.30 -4.4%
4.80 9.2%
0.70 0.1%
3.20 0.4%

GDC Facility Avg Daily Population*
Inmates per Direct Care FTE

44,276
55.41

4,546 10.3%
5.45 9.8%

48,822
60.85

*Population counts do not include contracted private and county prisons.
Source: GDC Staffing and Inmate Population Data

Mental Care Staff
Since fiscal year 2005, the number of budgeted mental health counselor positions has
increased by approximately 15% (see the Appendix) while the inmate population on
the mental health caseload increased by 12.2% (from 7,034 to 7,968). However, OHS
estimated that they were still 42 counselors short (about 20%) of their target
counselor-to-inmate ratios and that 10 of 26 facilities with a mental health caseload
are understaffed according to these ratios. It should be noted that OHS had 27
vacant counselor positions as of April 2007.
Our review also found no improvement in “Denial of adequate mental health care for
psychology and psychiatry staffing serious mental health needs may violate the
relative to the mental health caseload as eighth amendment under the same
illustrated in Exhibit 5 on the following deliberate indifference standard applied to
other medical needs… Additionally, there
page. From December 2004 to January must be some means of separating severely
2007, psychology hours increased by 4.8% mentally ill inmates from the mentally
(from 840 to 880 hours) and psychiatry healthy. Mixing mentally ill inmates with
hours were unchanged, while, as noted those who are not mentally ill may violate the
of both groups.”
above, the inmate population on the rights
Source: Guidelines for the Management of an
mental health caseload increased by Adequate Delivery System by the National
12.2%. Although there is no established Institute of Corrections (2001).
ratio of psychology or psychiatry staff
hours to the mental health inmate population, the annual mental health evaluations
from 2004 through 2007 discusses the lack of mental health staffing and its adverse
impact on mental care (see page 6 for the discussion of the mental health evaluation).

Exhibit 5
Psychiatry and Psychology Hours per Inmate on MH Caseload
1999-2007
0.35

Hours per MH Inmate

0.30
0.25
0.20

Psychiatry
Psychology

0.15
0.10
0.05

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9

0.00

Dental Care Staff
The number of budgeted dentist positions for GDC facilities has decreased by .5 FTE
from fiscal year 2005 to fiscal year 2007. As a result of the increasing inmate
population, the number of inmates per dentist has increased to 2,100, as shown in
Exhibit 6 below. Therefore, GDC would have required approximately nine
additional dentist positions to meet its target ratio of 1,500 during fiscal year 2007.
In its fiscal year 2008 budget request, GDC stated a new target of 1,200 inmates per
dentist. Although GDC was appropriated funds to hire three more dentists, bringing
the total to 26.25 FTEs, GDC will now require approximately 16 additional dentists
(approximately 42 total dentists) to attain the new goal.

Exhibit 6
Dentist Staffing in GDC Facilities
Budgeted Dentist FTEs
Avg Daily GDC Population

FY 2005 FY 2007 FY 2008
23.75
23.25
26.25
44,276 48,822 50,877
(projected)

Inmates per Dentist
GDC Targeted Inmates per Dentist
Additional Dentists Needed to Reach Target
Source: GDC Staffing and Inmate Population Data

1,864
1,500
5.77

2,100
1,500
9.30

1,938
1,200
16.15

Analysis of Correctional Health Care Costs
Health Care Cost Projection
In our 2004 report, we projected that costs per inmate would grow by 4% per year, resulting in fiscal
year 2006 total GDC health care costs of approximately $171.1 million.
Exhibit 7 below shows that total GDC health care costs for fiscal year 2006 were
$179.3 million, which is $8.2 million above our 2004 projection. According to
GCHC, one of the reasons for the higher costs has been the increase in health care
expenses for catastrophic inmate health claims. While GCHC financial reports
show they paid $7.4 million in medical claims for the 100 costliest inmates in fiscal
year 2004, this amount grew to over $13.8 million by fiscal year 2006, and was
projected to be approximately $18.5 million for fiscal year 2007; this equates to a
35.5% annual increase in this category. Partly as a result of the 100 costliest inmates,
GDC stated it was approximately $10.1 million over budget for its Health Program in
fiscal year 2007. At the time of our evaluation, GDC expected this amount to be paid
for with reserve funds from telephone commissions and commissary revenues, and
that this would deplete all of these reserve funds.

Exhibit 7
Total Health Care Cost Projection, Fiscal Years 2007 - 2011

Inmate Population
3
Cost Per Inmate
Total Costs

2

Actual

Projected

Annual
Increase

FY 2006
46,458
3,860
$179,344,251

FY 2007
FY 2008
FY 2009
FY 2010
FY 2011
48,822
50,877
53,019
55,251
57,578
4,037
4,221
4,414
4,616
4,826
$197,080,382 $214,760,135 $234,025,910 $255,019,986 $277,897,405

FY 2007 - 2011
4.21%
4.57%
8.97%

1

Notes:
1. For fiscal year 2007, the average daily inmate population was available and is presented; total correctional health care
expenditures, however, were not available and are projected.
2. This population includes inmates in GDC-operated facilities only, excluding county and privately operated prisons. The
projected annual increase of 4.21% in inmate population is based on a study by Rosser International, which is a GDC consultant.
3. The projected annual increase of 4.57% in inmate health care costs is based on historical increases from fiscal year 2003 to
fiscal year 2006.
Sources: GDC inmate population and financial records, Rosser International population analysis

Exhibit 7 also shows an updated five-year projection for fiscal years 2007 through
2011. The increase in the health care cost per inmate is based on GDC historical data
while the projected increase in the inmate population is based on a population
analysis performed by a GDC consultant (Rosser International). In fiscal year 2011, it
is projected that total GDC health care costs may be $278 million, which is
approximately $99 million higher than was expended in fiscal year 2006.

Decrease in Infirmary Beds
Our review determined that the number of functional male infirmary beds in GDC
state prisons decreased from 170 in 2004 to 156 in 2007. This is primarily due to the
conversion of Lee Arrendale State Prison to a female prison in 2005. As the inmate
population increased during this period, the utilization of these beds has, likewise,
increased from 83% to 91%.

To quantify the impact of bed space utilization on physical health care costs, GDC
recently estimated that 5.7 inmate hospital days per week (approximately 296 days
per year) could have been avoided had an infirmary bed within a GDC prison been
available. At the estimated daily average cost of $3,681 GDC pays hospitals for an
admitted inmate, this totals over $1 million annually. Although no calculation has
been performed to estimate how much it currently costs to operate a prison
infirmary bed, OHS and GCHC staff agreed this cost is low. At the time of this
report, OHS staff stated that 10 male infirmary beds at Lee Arrendale State Prison
would reopen in early fiscal year 2008.

Other States’ Correctional Health Care Costs
In order to compare costs to other states we obtained information from three of the
four states surveyed in our 2004 report. Exhibit 8 shows the health care cost per
inmate from 2003 through 2006 for these three states. Although the per-inmate cost
increase varied among the states, their average cost increase was 4.14%, slightly less
than Georgia’s 4.57% cost increase. According to the annual Corrections Compendium
produced by the American Correctional Association (ACA), the annual per-inmate
health care costs in state fiscal year 2005 for the 39 states responding to the survey
ranged from $2,205 (Texas) to $6,030 (Wyoming). The average for these 39 states
was $3,871.

Exhibit 8
Selected State Health Care Costs per Inmate
Georgia
Michigan
Pennsylvania
Virginia

2003
$3,376
$5,426
$3,917
$3,037

2004
$3,442
$4,946
$4,123
$3,221

2005
$3,760
$5,388
$4,271
$3,389

2006
$3,860
$5,929
$4,418
$3,637

Average Annual
Increase, 2003-2006
4.57%
3.00%
4.09%
6.19%

Source: Georgia, Michigan, Pennsylvania, and Virginia records

GDC and GCHC continue to employ the same cost containment measures used
in 2004.
In 2004, we reported that GDC and GCHC had established a number of permanent cost containment
measures including controls over pharmacy operations, negotiating provider contract rates, using
telemedicine, collecting inmate co-payments, and using utilization management. Additionally, we
concluded that GDC’s use of mandatory staffing vacancy rates also contributed to lowering costs,
although this measure could not be sustained without negatively impacting the quality of care. GDC
agreed with this finding.
Our updated review found that the permanent cost containment measures are still in
place. In particular, it appears GCHC’s efforts in actively managing pharmacy
operations and the drug formulary as well as negotiating discounts with hospitals
and other outside care providers have been effective in containing costs in these
areas. We also noted that GDC brought the utilization management (UM) function
in house, whereas it had previously been contracted out to MHM.

GCHC still achieves competitive discounts rates with outside health care
providers.
In 2004, we reported on a 2003 analysis by Price Waterhouse Coopers (PwC) that GCHC discount
rates negotiated with outside health care providers during fiscal year 2002 were competitive with
discounts attained by comparable “commercial/employer” health care plans.
As part of our review, we agreed to update the comparison of provider discount rates
achieved by GCHC to the rates achieved by the State Health Benefit Plan (SHBP).
Although we were unable to perform an adequate comparison on a provider-byprovider basis, we determined that the discount rates achieved by GCHC, in
aggregate, appear to be competitive with SHBP rates (given that some providers are
reluctant to provide care to inmates).
GDC and GCHC should consider contracting with outside professional consultants
to perform more detailed analyses of these rates to ensure GCHC continues to
achieve competitive discount rates with health care providers.

Before moving forward with a proposal to outsource the physical health care
services agreement currently in place with GCHC, GDC should quantify the
potential risks and benefits.
Our 2004 report found that OHS had established numerous management and operational controls
over the correctional health care system. This included controls over its relationship with GCHC, a
division of MCG. GDC agreed with this assessment, stating, “The partnership between GDC and
MCG has served the state well over the last seven years and is recognized nationally as a model for
correctional health care in the public sector.”
During our review, we were informed that GDC has considered the possibility of
outsourcing the health care agreement currently in place with GCHC. We also
learned that AT Kearney, in its role as a procurement consultant for the state,
reviewed this proposal and advised GDC that this action presented considerable risk
as it would involve rebuilding the complex health care delivery system already in
place. We agree with AT Kearney’s assessment, and agree that the partnership
between GDC and MCG has served the state well.
According to the 2007 evaluation performed by GDC’s physical health care
consultant:
“it is clear to me that despite a dramatic reduction in resources in central office,
at least at Central State Prison, the program continues to perform quite
satisfactorily. This has to be attributed to the stability of the Georgia
Department of Corrections’ partnership with [GCHC]. The leadership of GCHC
has been involved with the GDC now for several years, at both regional and
central office levels. They have been able to maintain stability of staffing at the
institutions, which has allowed the programs to sustain their level of clinical
quality…There is no question in my mind that if the Department chose to enter
into the competitive bid process in which vendors may change every three years or
every five years, the ability to sustain these programs would be dramatically
handicapped.”

Furthermore, according to the Association of Government Accountants (AGA), the
decision to outsource should only be made after performing appropriate cost
analyses and feasibility studies. Before proceeding with a proposal to outsource the
provision of physical health care, GDC should do the following:
•

•

Assess and quantify GCHC’s current “Some state systems have contracted
performance as the provider of physical out their entire health care delivery
system. The use of independent
health care for Georgia’s state inmates;

contractors, however, does not relieve
the institution (or the contractors) of
legal responsibility for health care.”

Quantify and document the expected
net benefits from moving to a private Source: Guidelines for the Management of
an Adequate Delivery System by the
vendor. GDC should also consider all National
Institute of Corrections (2001).
contract management controls and
performance monitoring activities that would be needed to effectively
monitor this new relationship.

Appendix
Budgeted Inmate Health Care Staffing in GDC Facilities
Fiscal Years 2005 and 2007
GDC
GCHC
MHM
2007

0.50
0.00
36.00
6.00
0.00
1.00
5.00

%
Change 2005

Total

2007

%
Change

2005

2007

%
Change

51.70
52.15
695.25
69.80
36.00
86.70
39.50

49.40
56.95
695.95
74.40
37.50
108.30
42.50

-4.4%
9.2%
0.1%
6.6%
4.2%
24.9%
7.6%

2005

2007

0.00 -100.0%
0.00
N/A
25.00 -30.6%
4.00 -33.3%
0.00
N/A
0.00 -100.0%
4.00 -20.0%

51.20
52.15
659.25
63.80
36.00
85.70
34.50

49.40
56.95
670.95
70.40
37.50
108.30
38.50

-3.5%
9.2%
1.8%
10.3%
4.2%
26.4%
11.6%

0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00

N/A
N/A
N/A
N/A
N/A
N/A
N/A

33.00

-32.0%

982.60

1032.00

5.0%

0.00

0.00

N/A

Mental
Psychiatrists
Psychologists
Counselors
Mental Health Nurses
Field Administrative Staff
Other Mental Health Staff

0.00
0.00
0.0%
0.00
0.00
0.0%
134.50 131.00 -2.6%
0.00
0.00
N/A
16.00 15.00 -6.3%
36.50 32.00 -12.3%

0.00
0.00
0.00
72.70
0.00
9.00

0.00
0.00
0.00
87.30
0.00
7.00

N/A
21.25 23.80
N/A
20.50 20.50
N/A
37.00 66.00
20.1% 2.00 1.50
N/A
3.00 4.00
-22.2% 4.00 7.00

12.0%
0.0%
78.4%
-25.0%
33.3%
75.0%

21.25
20.50
171.50
74.70
19.00
49.50

23.80
20.50
197.00
88.80
19.00
46.00

12.0%
0.0%
14.9%
18.9%
0.0%
-7.1%

Total Mental Health Care Staff

187.00 178.00

-4.8%

81.70

94.30

15.4% 87.75 122.80

39.9%

356.45

395.10

10.8%

Dental
Dentists
Dental Hygienists
Dental Assistants

15.75
6.00
23.75

12.50
5.00
23.00

-20.6%
-16.7%
-3.2%

1.00
0.50
1.00

1.00
0.50
1.00

0.0%
0.0%
0.0%

7.00
0.00
2.00

9.75
0.00
5.00

39.3%
N/A
150.0%

23.75
6.50
26.75

23.25
5.50
29.00

-2.1%
-15.4%
8.4%

Total Dental Health Care Staff

45.50

40.50

-11.0%

2.50

2.50

0.0%

9.00

14.75

63.9%

57.00

57.75

1.3%

Clerk
Secretary

17.00
28.50

13.00
23.00

-23.5%
-19.3%

0.00
13.00

0.00
0.00

N/A
3.00
-100.0% 0.00

0.00
0.00

-100.0%
N/A

20.00
41.50

13.00
23.00

-35.0%
-44.6%

Total Other Staff

45.50

36.00

-20.9%

13.00

0.00

-100.0% 3.00

0.00

-100.0%

61.50

36.00

-41.5%

Total Budgeted Facility Staff

326.50 287.50 -11.9% 1,079.80 1,128.80

Physical
Physicians
Clinical Practicioners
Nurses
Pharmacy
Field Administrative Staff
Support Staff
Other Staff

2005

%
Change

Total Physical Health Care Staff 48.50

1,031.10 1,065.00

3.3%

Other

Source: FY 2005 and 2007 Staffing Plans

4.5%

99.75 137.55

37.9%

1,506.05 1,553.85

3.2%

For additional information or for copies of this report call 404-657-5220 or see our website:
http://www.audits.state.ga.us/internet/pao/rpt_main.html