PERFORMANCE AUDIT Georgia Farmworker Health Program Department of Community Health May 2003 Performance Audit Operations Division Russell W. Hinton, State Auditor Department of Audits and Accounts 254 Washington St. Atlanta, GA 30334 Background The mission of the Georgia Farmworker Health Program is to improve the quality of life of Georgia's migrant and seasonal farmworkers and their families by providing cost-effective, culturally appropriate primary health care and by arranging for other levels of health care through collaboration and advocacy. The Georgia Farmworker Health Program is administered by the Department of Community Health's Office of Rural Health Services. For fiscal year 2003, the Program is budgeted to expend $2.3 million, of which $1.8 million is federal funds and $441,224 is state general funds. The Program's healthcare goals, as outlined in its federal funding application for 2003, are to: improve migrant and seasonal farmworkers' access to health care services; assure that the Program's objectives are consistent with the needs of the migrant and seasonal farmworkers; assure the delivery of effective, high-quality primary healthcare services; improve the health status of migrant and seasonal farmworkers, including their children and spouses; improve the pregnancy outcome of farmworker women; and, improve the Program's health education and outreach components. Under federal law, migrant and seasonal farmworkers are defined as persons whose principal employment is agriculture on a seasonal basis; migrant workers, however, travel from job to job without establishing a permanent residence at any job site. Approximately 89% of the migrant and seasonal farmworkers are migrant workers and 11% are seasonal workers. The Program contracts with five providers to deliver primary health care services in 21 rural counties in the southern part of the state. As shown by Exhibit 1 on the following page, the five providers include three Boards of Health, one hospital, and one private clinic. The Tattnall County Board of Health operates two clinics: one in Glennville and one in Douglas (at the Coffee County Health Department). The Decatur County site was established by the Program in June 2002. Although the project sites are required to serve any eligible person who comes to their clinics, they only conduct outreach activities in the counties within their service areas. Georgia Farmworker Health Program Page 1 Provider Sumter Regional Hospital Decatur County Board of Health Exhibit 1 GEORGIA FARMWORKER HEALTH PROGRAM Project Site (Location) Contract Amount 2003 Counties Served Ellaville (freestanding clinic) $377,525 Crisp, Macon, Schley, Sumter, Taylor Bainbridge (Decatur County Health Department) $488,419 Decatur, Grady, Thomas, Seminole, Mitchell Colquitt County Board of Health Airport Medical Clinic, Inc. Ellenton (freestanding clinic) Lake Park (freestanding clinic) $449,579 $249,035 Brooks, Colquitt, Cook, Tift Echols, Lowndes Tattnall County Board of Health Douglas (Coffee County Health Department) $555,361 Atkinson, Coffee Source: Program records Glennville (Tattnall County Health Department) Candler, Tattnall, Toombs Outreach activities include visiting the farms and the workers' camps to provide basic health care education and to make the workers aware of the Program's services. Exhibit 2 on the following page shows the location of the project sites and their service areas. As shown on the map, all of the project sites are situated in the southern part of the state, where the majority of the farmworkers are located. The number of migrant and seasonal farmworkers located in the northern part of the state is estimated to be 2,466, or approximately 2% of the 114,302 farmworkers estimated to be in the state during the peak farming season. These persons work primarily in the apple orchards during the brief harvesting season. Program History and Organization The Georgia Farmworker Health Program was established in 1990 within the Department of Human Resources' Office of Primary Care. In January 2000, the Program was transferred to the Office of Rural Health Services within the Department of Community Health (DCH). The new Office of Rural Health Services was subsequently moved from Atlanta to Cordele, Georgia, in part, to better serve the needs of rural and other underserved populations (per DCH personnel). The Program is administered by the Director of Migrant, Homeless and Special Programs within the Office of Rural Health Services. In addition to the Director, the Program has four part-time positions: a program consultant, a field data consultant, and two administrative personnel. The Program staff are responsible for administering the contracts with the providers, maintaining a database of program activities, and providing technical assistance to the project sites. Georgia Farmworker Health Program Page 2 Program Services To be eligible for the Program, farmworkers must, per federal regulations, perform farm work that specifically includes cultivation, tillage, growing, harvesting, and preparation and processing [of agricultural products] for market or storage. In Georgia, this would include such crops as cabbages, cantaloupes, cucumbers, greens, okra, onions, peaches, peppers, corn, sweet potatoes, squash, tobacco, tomatoes, and watermelons. Citizenship or legal status is not required for Program eligibility. Exhibit 2 GEORGIA FARMWORKER HEALTH PROGRAM PROJECT SITES LEGEND GFHP Project Site Ellaville Primary Medicine Clinic Decatur County Health Department Ellenton Clinic Airport Medical Clinic Coffee County Health Department Tattnall County Health Department NOTE: The shaded areas represent the targeted service area for each project site. SOURCE: Program Records Although the state has become dependent on migrant and seasonal farmworkers to plant and harvest crops, most farmworkers live at or below the national poverty level and are uninsured, thus increasing the demand for healthcare services in the communities where they live and work. Conditions such as occupational injuries, heart disease, dental disease, diabetes, pesticide exposure, and under and over-immunization are documented health issues for the farmworker population. Many of the farmworkers do not speak English and are unaware of the health services available to them because of language barriers. According to Program data, 78% of the migrant and seasonal farmworkers require the use of an interpreter Georgia Farmworker Health Program Page 3 during medical visits. Because of additional factors such as a lack of transportation, the population has experienced difficulties in accessing preventive health care. In order to receive services, farmworkers must register annually at one of the Program's project sites. Farmworkers may be registered at the time medical services are received, or by clinic staff at the farms where they work or at the camps where they live. Once registered, farmworkers receive identi-fication cards (with assigned identification numbers) which they may use at any project site as proof of their eligibility for services. This registration assists the sites in maintaining a medical history of their registered users. The types of primary health services provided by the Program include: Airport Medical Clinic - Lake Park, GA The Program's only privately operated clinic. Diagnosis and treatment of illness; Preventive health services; Laboratory, radiology, and pharmacy services; Outreach services, including interpretation and transportation; Case management; and Health education. According to Program guidelines, Program funds cannot be used for inpatient hospitalization, home health care, or restorative dental work. The Program generally uses mid-level providers (nurse practitioners) to provide primary healthcare, with referrals to physicians as needed. As specified in their contracts, the five providers are required to participate in the Program's quality assurance activities, including periodic audits of patients' charts and quarterly peer reviews of patients' charts conducted by Program clinicians. The Program contracts with local physicians to provide these clinical reviews. Bilingual outreach workers at each project site provide case management, health education, and translation services. In 2002, the Program received the Sister Cecilia Abhold Award for excellence in outreach activities in the eastern region of the U.S. The award is presented annually by Farmworker Health Services, Inc., whose mission is to improve the quality of life for the nation's farmworkers. The criteria for the award include the provision of linguistically and culturally appropriate health care, innovative health education programs, and leveraging of community resources. When needed services cannot be provided by the project site, farmworkers are given vouchers to obtain specialty services from another healthcare provider. Each site is responsible for entering into agreements and/or contracts with other providers for these services. The maximum amount the Program will pay for services from an outside provider is equal to the Medicaid rate for those services. Vouchers are also provided to enable the farmworkers to obtain prescription drugs. Georgia Farmworker Health Program Page 4 Financial Information For fiscal year 2003, the Program was budgeted $2,271,422, including $1,830,198 in federal grants; and $441,224 in state general funds. Exhibit 3 below shows the expenditures for the Program for fiscal year 2002 and the budgeted amounts for 2003. As shown by the Exhibit, the Program's budget was increased by about $1 million for 2003; the additional funds are for the Decatur County project site and for additional personnel at the other project sites (Expanded Medical Capacity grant). The Program's federal funds are obtained from the Bureau of Primary Health Care within the U.S. Department of Health and Human Services' Health Resources and Services Administration. The Bureau administers federal funds distributed in accordance with the Migrant Health Program. The Migrant Health Program (MHP) provides grants to community nonprofit organizations for a variety of culturally and linguistically competent medical and support services to migrant and seasonal farmworkers and their families. Exhibit 3 FUND SOURCES AND EXPENDITURES FISCAL YEARS 2002 AND 2003 FISCAL YEAR FUND SOURCES 2002 2003 ACTUAL BUDGETED Federal $965,819 $1,830,198 State 291,224 441,224 TOTAL $1,257,043 $2,271,422 EXPENDITURES Personal Services Regular Operating Expenses $56,599 5,893 $103,164 8,000 Travel Equipment 12,385 0 20,000 6,500 Computer Charges 10,635 Per Diem and Fees Contracts(1) 11,531 1,160,000 TOTAL $1,257,043 (1)Patient care contracts with the five providers. 2,000 11,839 2,119,919 $2,271,422 Source: Program and Department of Community Health financial records. Georgia Farmworker Health Program Page 5 In addition to their contract funds, the providers may also obtain direct grant funding or donations from other sources, such as community groups, medical institutions, and local medical care providers. The providers also obtain funds from fees charged the farmworkers for the services provided to them. The fees are assessed using a sliding scale based on income and federal poverty guidelines. The sites may also establish and charge a minimum flat fee for services; however, services cannot be denied to patients who are unable to pay the minimum fee. The income generated from these fees is retained by the providers and may be carried over to the following grant year. The Program's collection rate for private pay fees (based on the sliding fee scale) is approximately 68%. Because the Program's funds are limited, the Program will assist the farmworkers in establishing eligibility for other programs, such as Medicaid or Medicare. Arrangements may also be made for care to be provided within the local health departments whenever possible. Activity Data The Program served 11,171 migrant and seasonal farmworkers and their families during calendar year 2002. The number of persons served by each of the providers is indicated below: Sumter Regional Hospital (Ellaville): 1,402 Decatur County Board of Health (Decatur County Health Department): 1,029 Colquitt County Board of Health (Ellenton): 2,898 Airport Medical Clinic (Lake Park): 1,855 Tattnall County Board of Health (Tattnall County Health Department): 3,076 Tattnall County Health Department: (Coffee County Health Department): 911 It should be noted that the Decatur County project site did not become operational until June 2002. Audit Objectives, Scope, and Methodology The primary objectives of this audit were to determine whether: the Program's service delivery efforts are directed in those areas of the state where the services are most needed; the Program has accurately identified the number of farmworkers in the state who are eligible for its services; the Program has established uniform payments for its patient care contracts; and, the Program's administrative activities are being carried out efficiently. The audit was conducted in accordance with generally accepted government auditing standards for performance audits and focused primarily on grant year 2002 (June 1, 2001 May 31, 2002) and calendar year 2002. The audit methodology included reviews of Program records and interviews with Program staff within the Department of Community Health and with personnel at each of the project sites. Interviews were also conducted with Georgia Farmworker Health Program Page 6 personnel at five health departments, one community health center, and the Medical Director of a public health district in the state.1 The health departments visited were located in counties that are not currently included within the Program's service area, but are estimated to have significant numbers of migrant and seasonal farmworkers during peak season. We also spoke with personnel within the Bureau of Primary Health Care within the U.S. Department of Health and Human Services' Health Resources and Services Administration. It should be noted that the scope of the audit did not include an evaluation of the housing and working conditions of the migrant and seasonal farmworkers or the quality of the medical services provided by the Program. This report has been discussed with appropriate personnel representing the Department, and a draft copy was provided for their review and comment. Pertinent responses received from the Department have been incorporated into this report as appropriate. (1) The health departments visited were located in Peach, Bacon, Jeff Davis, Dooley, and Wilcox counties. Georgia Farmworker Health Program Page 7 Recommendations and Agency Responses Recommendation No. 1 Action should be taken where possible to increase the number of counties served by the Program. Although the Program should be commended for focusing on those counties with the largest numbers of migrant and seasonal farmworkers, about 33% of the Program's target population live outside the Program's service areas. Of the 114,302 migrant and seasonal farmworkers estimated to be in the state during the peak farming season, about 37,320 are in counties that are not served by the Program. As shown by Exhibit 4 on the following page, 10 of the 28 counties with more than 1,000 farmworkers1 are not served by any of the project sites. Eight of these 10 counties, however, are adjacent to an existing service area. If these eight counties could be included in the existing service areas, the number of migrant and seasonal farmworkers covered by the Program would be increased by 25%, from 76,982 to 96,092. This would increase the percentage of farmworkers covered by the Program from 67% to 84%. The Program should continue its efforts to expand the number of counties it serves. In addition to adding the Decatur project site in 2002, the Program has posted a Request for Proposal (RFP) to healthcare agencies for the purpose of establishing a project site to serve Wilcox County (estimated to have approximately 4,500 migrant and seasonal farmworkers during the peak farming month). It should be noted that federal funding guidelines specify that once a provider's service area is established by the Program, it cannot be modified without adding an additional access point for providing services. Additionally, only one new project site may be added to the Program per year. In its written response, the Department of Community Health stated that the Program will continue to expand its services into those counties with the most significant need, based on the farmworker population. The Department also noted that although federal guidelines would not allow Expanded Medical Capacity funds to be used for expansion into the eight adjacent counties, those counties would be considered for expansion if other state or federal funding becomes available. Recommendation No. 2 The Program should take steps to obtain more up-to-date information regarding the number and location of migrant and seasonal farmworkers in the state. Currently, the Program relies on a 1995 study conducted by the University of Georgia to make decisions regarding the location of project sites and the amount of funding provided the sites. The study was conducted by the University of Georgia's Institute of Community and Area Development (ICAD) using trends in the acreage of labor-intensive crops from 19871994. The estimates of peak eligible population were developed to help anticipate the demands that the clinics would face at the busiest times of the year. As part of the performance audit, the audit team visited five county health departments that were estimated to have significant numbers of farmworkers, but were outside of the Program's targeted 1Migrant and Seasonal Farmworkers in Georgia, Estimates of the Migrant Health Program Target Population, 1995 Georgia Farmworker Health Program Page 8 service areas. Of the five health departments, all five indicated that the population estimates used by the Program overstated the number of migrant and seasonal farmworkers in their counties (based on the number of farmworkers they served in their clinics). at those areas of greatest need. According to federal law, non-grant monies (such as state, local, and other operational funding or Program income from client fees) may be used for purposes that are not specifically prohibited by the law... if such use furthers the objectives of the project. The Office of Rural Health Services should consider using Program funds to conduct a new study to determine the current migrant and seasonal farmworker population in the state. Obtaining current data would serve to ensure that available Program resources and future expansion efforts were directed In its written response, the Department noted that it concurred with the recommendation and has initiated discussion with a demographic expert to explore possible ways to obtain updated farmworker population data, contingent upon available funding. Exhibit 4 ESTIMATED NUMBER OF FARMWORKERS IN GEORGIA DURING PEAK SEASON Legend GFHP Project Site Project Site Target Areas Counties Outside of Project Site Target Areas with more than 1,000 Farmworkers and Dependents 2,988 1,093 2,307 2,050 4,513 1,733 4,432 1,010 1,034 1,993 Source: Migrant and Seasonal Farmworkers in Georgia, Estimates of the Migrant Health Program Target Population, 1995 Georgia Farmworker Health Program Page 9 Recommendation No. 3 The Program should consider revising the dollar amount of its contracts with the five service providers based on the estimated number of farmworkers in the providers' service areas. Program personnel have indicated that the dollar amounts of the providers' contracts were based on the providers' original proposals regarding the numbers of users and encounters. Our review of the current contract amounts, however, found that they do not reflect the number of actual users or the number of migrant and seasonal farmworkers potentially in need of health care in each of the providers' service areas. Our review of the 2002 contract amounts found that they ranged from $90 per user to $176 per user (as shown in Exhibit 5 below). Our review also found that the contract amounts are not in line with the estimated number of farmworkers in each provider's service area. For grant year 2002, the dollar amount of each service provider's contract ranged from $14 to $54 per estimated farmworker in the providers' service areas (as shown in Exhibit 5 below). An analysis of the contract amounts for grant year 2003 shows a similar pattern; the contract amounts range from $16 to $71 per estimated farmworker. Because the dollar amount of the providers' contracts determines the number of personnel they can employ (and have more personnel per farmworker), the sites that receive more per farmworker do a better job of registering farmworkers for Program services. As shown in Exhibit 5, the two sites whose contract amounts were equal to $14 and $19 per farmworker, only registered 7% and 8% of the farmworkers in their service areas, respectively. Conversely, the two sites that received $38 and $54 per farmworker registered 37% and 29% of the farmworkers in their service areas, respectively. Exhibit 5 CONTRACT AMOUNTS AND ACTIVITY DATA FUNDING YEAR 2002 Provider Contract Amount 2002 Contract Contract Amount Per Amount Per User Farmworker Number of Farmworkers Registered (As of June 2002)1 Sumter Regional Hospital Colquitt County Board of Health $180,000 $325,000 $143 $93 $14 6% (830 of 12,927) $19 8% (1,436 of 17,383) Tattnall County Board of Health $465,000 $176 Airport Medical Clinic, Inc. $190,000 $90 Decatur County Board of Health N/A2 N/A 1Number of farmworkers registered from January--June 2002. 2The Decatur County project site did not become operational until June 2002. Source: Program records $38 37% (4,499 of 12,127) $54 29% (1,009 of 3,522) N/A N/A Georgia Farmworker Health Program Page 10 The Program should consider basing the contract amounts on the estimated number of farmworkers within the providers' service areas. This would provide a more equitable basis for the current contracts, as well as in determining the contract amounts for any future project sites. If the Program continues to pay the providers based on the number of users and encounters, then the providers should be held accountable for meeting the minimum number of users and encounters that are specified in the contracts (as discussed in the following Recommendation). In its written response, the Department indicated that revising the contract amounts based on the estimated number of farmworkers in the targeted service areas is not feasible because of federal funding guidelines. Recommendation No. 4 The Program should hold the providers responsible for meeting performance standards that are reasonable and reflective of past performance. Although performance standards are included in the providers' contracts, they are not up-to-date and are not accurate measures for assessing performance. As a result, the Program cannot hold the providers accountable as a condition of payment. The Program pays each contractor monthly based on their actual expenditures, regardless of the number of persons receiving services. Exhibit 6 below shows the performance standards included in the providers' contracts in 2002 and 2003 and the providers' actual performance in 2002. As shown by the Exhibit, the Program did not revise the performance standards in grant year 2003 to reflect the providers' actual performance. Although the Tattnall County Exhibit 6 PERFORMANCE TARGETS INCLUDED IN PROVIDER CONTRACTS Provider Contract Requirement Grant Year 2002 Contract Actual Activity Requirement Grant Year 2002 Grant Year 2003 Sumter Regional Hospital 1,260 users 1,581 users 1,260 users Airport Medical Clinic, Inc. 2,100 users 1,659 users 2,100 users Tattnall County Board of Health 1 2,635 users 4,280 users 2,635 users Colquitt County Board of Health 2 3,488 users 2,666 users 3,488 users Decatur County Board of Health 3 N/A N/A N/A 1The Tattnall County data includes user data from the Coffee County Health Department as well as the Tattnall County Health Department project sites. 2The project site contract for Colquitt County specifies a performance target as a minimum number of encounters. 3The Decatur County project site did not become part of the Program until June 2002. Source: Program Records and Patient Care Contracts Georgia Farmworker Health Program Page 11 Board of Health, for example, had almost 4,300 users in grant year 2002, the performance standard for grant years 2002 and 2003 remained unchanged at 2,635 users. Conversely, the Program took no action regarding Airport Medical even though it served 441 (21%) fewer users than specified in its contract. The Program did not levy any type of financial penalty against the provider nor did it revise the performance standard for 2003. It should also be noted that the performance standard for the Colquitt County Board of Health specifies a minimum number of encounters. The standards for the other providers specify a minimum number of users. The Program should develop realistic performance standards based on prior performance and should include the revised standards in the providers' contracts. The providers should be held accountable for meeting the standards as a condition of payment. In its written response, the Department noted that the Program is in the process of gathering statistics to determine appropriate targets for users and/or encounters which will be subsequently amended into the project site contracts. The Department also indicated that the Program will continue to monitor the project sites' performance to ensure that Program goals and objectives are being met. Recommendation No. 5 To the extent possible, the Program should establish uniform procedures regarding the administrative activities carried out by the project sites. On-site reviews of all of the project sites found that a number of Program functions are being carried out differently by each project site, including fee charges and collections, as well as the development of identification cards for Program clients, and a database network for medical records. These issues are described in greater detail below. The Program should establish a minimum flat fee that providers charge patients whose income is at or below the federal poverty level. Of the five service providers, two charge a minimum flat fee of $25 while three charge a minimum flat fee of $15. The Program's current guidelines only specify that providers should charge a minimum flat fee if a family's income is at or below the federal poverty level; the amount of the fee is not specified. The Program should ensure that all of the providers develop written policies and procedures for handling patient payments. According to program guidelines, the project sites are required to have written financial and billing policies and procedures. However, none of the project sites visited by the audit team could provide copies of their policies. The Program should develop a standard identification card that is required to be used by all project sites. This would help to more easily identify persons eligible for the Program. According to Program officials, a uniform identification card has been developed but is currently being used by only one project site. The Program should continue to work toward developing a computer network for tracking the medical records of persons seen by the providers. Although the migrant workers may be seen at multiple project sites as they follow the crops, Georgia Farmworker Health Program Page 12 separate medical records are maintained at each project site. Putting such a network in place would make it easier for the project sites to assess eligibility for services and better track the health needs of the population and provide continuity of medical care for the population. Prior to the release of this report, Program personnel indicated their agreement with the need to develop a uniform flat fee for services and to require providers to develop written procedures for handling patient payments. Program personnel also indicated that they were in the process of developing a computer network for maintaining persons medical records. A completion date for the project has not yet been established, however. In its written response, the Department indicated that the Program is in the process of updating its Guidelines for Operations manual which, once completed, will provide a uniform approach for administrative procedures and reporting. For additional information, please contact Paul E. Bernard, Director, Performance Audit Operations Division, at 404.657.5220. Georgia Farmworker Health Program Page 13