2000 annual report

BROC Budgetary Responsibility Oversight Committee
2000 ANNUAL REPORT
THE GENERAL ASSEMBLY STATE OF GEORGIA

2000 Members of the Budgetary Responsibility Oversight Committee
Senator George Hooks, Co-Chair and Chair of Senate Appropriations Committee Senator Nathan Dean, Chair of Senate Finance and Public Utilities Committee Senator Jack Hill, Chair of Higher Education Committee Senator Terrell Starr, President Pro Tempore Senator David Scott, Chair of Senate Rules Committee Senator Charles W. Walker, Majority Leader
Representative Terry L. Coleman, Co-Chair and Chair of House Appropriations Committee Representative Tom Buck, Chair of House Ways and Means Committee Representative Butch Parrish, Chair of House Banks & Banking Committee Representative Calvin Smyre, Chair of House Rules Committee Representative Ralph Twiggs, Chair of House Public Safety Committee Representative Larry Walker, Majority Leader
BROC Research Office Staff
Kevin Fillion, Director Kisha Wesley, Senior Performance Evaluator Mary Courtney Hurst, Performance Evaluator
Fred Miller, Performance Evaluator Glynnell Lewis, Office Manager
Phone: 404.657.4600 Fax: 404.657.4606
Email: glewis@legis.state.ga.us Internet Address:
http://www.broc.state.ga.us

March 2001
Chairman's Report to Members of the General Assembly and the Governor:
To improve the quality of the information BROC reviews, we continued, over the past year, to review specific areas of the continuation budget that we think warrant legislative oversight. The BROC staff has been very busy with these special assignments. This targeted approach is helping agencies produce documents that are meaningful and useful to legislators.
For example, the BROC staff, under our direction, worked with the House and Senate Human Development Subcommittees of Appropriations to hold five oversight hearings on the Temporary Assistance for Needy Families Block Grant, the Child Care Development Fund, and the Social Services Block Grant. The joint committee found that the information currently collected for these block grants is not sufficient for legislative decision making. Additionally, the committee determined that the state is not taking advantage of the flexibility inherently established in these block grants. The legislature is now reviewing the block grants on a regular and routine basis. BROC commends the work of this joint committee.
For the upcoming year, we have directed the BROC Research staff to continue to analyze funds not contemplated by an appropriations act and other federal fund sources--two areas that warrant more legislative oversight.
In the fall, the director of our Research Office resigned to work in the private sector. We were fortunate to have a qualified applicant in the deputy director position. We promoted Kevin Fillion to the director position and have experienced a smooth transition.
The Budgetary Responsibility Oversight Committee commends the staff from the Department of Audits and Accounts for their invaluable aid to the committee during 2000.
In summary, and in accordance with O.C.G.A. 28-5-5(f), the Budgetary Responsibility Oversight Committee submits this annual report of committee activities. This annual report is a full accounting of the activities of the committee during the last calendar year.
Sincerely,
Terry Coleman Representative, District 142 2000 Chair, Budgetary Responsibility Oversight Committee

TABLE OF CONTENTS
Selected sections of the Budget Accountability and Planning Act of 1993 .... 1
2000 Evaluation List......................................................................................3
Adult Protective Services ...........................................................................................5
Indigent Care Trust Fund...............................................................................6
1999 Evaluation List......................................................................................7 Access to Primary Care Services .....................................................................9 Indigent and Uncompensated Care ................................................................ 14 Public Water Systems' Drinking Water Quality ................................................. 20

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Selected sections of the Budget Accountability and Planning Act of 1993: Code Section 28-5-5: (a) There is created the Budgetary Responsibility Oversight Committee which shall be composed of six members
of the House of Representatives appointed by the Speaker of the House of Representatives and six members of the Senate appointed by the President of the Senate. The members of such committee shall be selected within ten days after the convening of the General Assembly in each odd-numbered year and shall serve until their successors are appointed. (b) The Speaker of the House of Representatives shall appoint a member of the committee to serve as chairperson and the President of the Senate shall appoint members of the committee to serve as vice chairperson and secretary during each even-numbered year. The President of the Senate shall appoint a member of the committee to serve as chairperson and the Speaker of the House of Representatives shall appoint members to serve as vice chairperson and secretary during each odd-numbered year. Such committee shall meet at least six times each year and, upon the call of the chairperson, at such additional times as deemed necessary by the chairperson. (c) It shall be the duty of such committee to consult with the Governor and the Office of Planning and Budget concerning the development and implementation of the strategic planning process, the development of outcome measures for program evaluation, and the implementation of related actions. (d) It shall be the duty of such committee to review and evaluate the following: (1) Information on new programs submitted in accordance with Code Section 45-12-88; (2) The continuation budget report submitted in accordance with Code Section 45-12-75.1; (3) The strategic plans for the state and individual departments submitted by the Office of Planning and
Budget; (4) Program evaluation reports submitted in accordance with Code Section 45-12-178; (5) Information or reports to be submitted by the Office of Planning and Budget identifying moneys received
and purposes for which moneys are expended in any case in which the receipt or expenditure is not contemplated by an appropriations Act; and (6) Such other information or reports as deemed necessary by such committee. (e) The Office of Planning and Budget and the head of each budget unit shall cooperate with such committee and provide such information or reports as requested by the committee for the performance of its functions. (f) The committee shall make an annual report of its activities and findings to the membership of the General Assembly and the Governor within one week of the convening of each regular session of the General Assembly. The chairperson of the committee shall deliver written executive summaries of such report to the members of the General Assembly prior to the adoption of the General Appropriations Act each year. (g) The members of the committee shall receive the allowances authorized for legislative members of legislative committees. The funds necessary to pay such allowances shall come from funds appropriated to the House of Representatives and the Senate. (h) The committee shall be authorized to request that a performance audit be conducted for any department which the committee deems necessary.

Code Section 45-12-75.1: (a) On or before October 1 of 1994 and each year thereafter, the Governor, through the Office of Planning and
Budget, shall prepare and submit to the Budgetary Responsibility Oversight Committee a continuation budget report. On or before May 1 of 1994 and every year thereafter, the Governor, through the Office of Planning and Budget, shall consult and coordinate with the chairperson of the Budgetary Responsibility Oversight Committee to develop a list of agencies and programs in agencies which will be included in the continuation budget report for the year. Each state department shall be included in the continuation budget report not less than once every five years. The continuation budget report shall contain a detailed analysis of the funds necessary to provide services in the current fiscal year for each state agency and program examined. Such report shall address all programs and shall include a description of the purposes and accomplishments of the programs. (b) The committee shall consider the budget report prepared pursuant to this Code section in conjunction with the audit report prepared pursuant to paragraph (4) of Code Section 50-6-24. (c) The committee shall submit to the membership of the General Assembly within one week of the convening of each regular session of the General Assembly a list of all programs included in the continuation budget report for each department examined as well as actions recommended, if any, by the committee. (d) It is the intent of this Code section to examine all state departments not less than once every five years.

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Code Section 45-12-88: When any budget unit has plans to institute any new program, it shall be the duty of the head of such unit to furnish to the Budgetary Responsibility Oversight Committee, on September 1 prior to the convening date of the session at which appropriations to finance such program are to be sought, a description of the program, the reason for seeking to institute such program, the operating procedure of such program, the manner in which it conforms to the organization's strategic plan as well as the state strategic plan, the extent to which the facilities and staff to implement or provide the program will be decentralized, and any other information which would be helpful to the members of the committee in determining whether or not to appropriate funds therefor. The members shall also be furnished with the projected cost to implement the program fully.
Code Section 45-12-178: (a) It is the intent of the Governor and the General Assembly that taxpayers' money be spent in the most effective
and efficient manner possible in order to obtain the maximum benefit from such expenditures. In furtherance of this objective, the Governor, through the Office of Planning and Budget, shall assist the General Assembly in establishing an ongoing review and evaluation of all programs and functions in state government. (b) The chairperson of the Budgetary Responsibility Oversight Committee shall maintain a list of those programs for which the committee is requesting evaluations. The chairperson shall provide the list, and any subsequent revisions to the list, to the director of the Governor's Office of Planning and Budget and to the state auditor. (c) The Office of Planning and Budget, the Department of Audits and Accounts, and the Research Office of the Budgetary Responsibility Oversight Committee shall undertake and complete evaluations on as many of those requested programs as resources will permit. The Office of Legislative Budget Analyst, the Board of Regents of the University System of Georgia, and all other state agencies are authorized and directed to provide assistance to the Office of Planning and Budget, the Department of Audits and Accounts, and the Research Office of the Budgetary Responsibility Oversight Committee, as requested, in the performance of these evaluations. The Office of Planning and Budget, the Department of Audits and Accounts, and the Research Office of the Budgetary Responsibility Oversight Committee are also authorized to contract with private contractors to perform, or assist in the performance of, these evaluations. (d) The Office of Planning and Budget, the Department of Audits and Accounts, and the Research Office of the Budgetary Responsibility Oversight Committee shall report to the Budgetary Responsibility Oversight Committee on the results of program evaluations as such evaluations are completed. Such reports shall include: (1) Appropriate background information on the affected program, including how and why it was initiated, its
functions, what group it serves, how it is organized structurally and geographically, what are its staff size and composition, and what is its workload; (2) Financial information including the source and amounts of funding and unit costs, where applicable; (3) A description of the program's mission, goals, and objectives and an assessment of the extent to which the program has performed in comparison; (4) Comparisons with other applicable public and private entities as to their experiences, service levels, costs, and staff resources required; (5) Recommendations concerning the program, including whether it should be continued as it is currently operated, continued with identified steps to remediate deficiencies or institute improvements, or discontinued. Consideration should also be given to possible privatization or consolidation with other similar programs; (6) Information describing the locations at which the program is operated and administered and the extent to which the operation and administration could be decentralized; and (7) Such other information as is identified as appropriate. (e) It is the intent of the General Assembly that all programs be evaluated at least every ten years. (f) Department heads shall respond, in writing, within 90 days of the receipt of the report to recommendations and findings by the Office of Planning and Budget or the Department of Audits and Accounts setting forth in detail the action to be taken by said department to address the recommendations and findings. Said written response shall be made to the Office of Planning and Budget, the Department of Audits and Accounts, and the Budgetary Responsibility Oversight Committee. (g) The Research Office of the Budgetary Responsibility Oversight Committee shall verify with state departments the implementation of the departments' plans set forth in their 90 day responses as submitted in accordance with subsection (f) of this Code section. The Research Office shall inform the Budgetary Responsibility Oversight Committee about each department's progress at reasonable intervals.

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2000 Evaluation List

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Status Report for the 2000 Evaluation List

Title Adult Protective Services Indigent Care Trust Fund Public Well-Being through Vital Communities Study of Library Services to Special Needs Populations in Georgia Analysis of Agency Overtime Practices
Conveyance of Property
Correctional Industries Fuel Surcharge Policy TANF Unobligated Balances
Questions about Wright Express Fleet Card for State Use Implementation of O.C.G.A. 36-81-8.1: Grants to Local Governments The Georgia Academy for Children and Youth Professionals. Inc. Central State Hospital Ambulance Service Outsourcing South Georgia Regional Board
Rep. Snow's Letter to Rehabilitative Services on Counselor Training Eastman YDC
Roadside Historical Markers
Victoria Bryant State Golf Course
Policies at Georgia College & State University: No State Funds Used for Commencement Trip and Ceremony; Formal Policy Governs Use of Mansion Curriculum on Accessibility Design for Persons with Disabilities for Education of Engineers, Architects, & Tech School Enrollees Georgia Indigent Defense Council Funding to Local Program Performance Audit Human Development Legislative Oversight Meetings Statewide Inventory of Contracts for Outsourced Functions/Services and Consultant Services (including Interagency Contracts). Community Care Services Program and Aging Services
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Assigned to Audits Audits
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BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research BROC Research
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Audits
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OPB

Status of Report A summary follows this page A summary follows this page. Annual Strategic Planning Conference held at GWCC on January 6, 2000. Cancelled because DTAE contracted with a private vendor to study this. See the BROC Research Office for a copy of this analysis. See the BROC Research Office for a copy of this analysis. See the BROC Research Office for a copy of this analysis. See the BROC Research Office for a copy of this analysis. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter.
See the BROC Research Office for a copy of this letter.
See the BROC Research Office for a copy of this performance audit.
See the BROC Research Office for a copy of this report. See the BROC Research Office for a copy of this special report.
This report was cancelled by OPB.
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Adult Protective Services
Evaluated: December 2000 by the Department of Audits and Accounts
The overall purpose of Adult Protective Services mandated under the Georgia Disabled Adult and Elder Person Protection Act is to protect disabled (mentally or physically) adults (18 years of age and older) and elder persons (65 years of age and older) who are not residents of long-term care facilities from situations of domestic abuse, neglect, and exploitation (A/N/E). The Department of Human Resources' APS Program is responsible for receiving and investigating reports of A/N/E, deterring the ongoing maltreatment of disabled adults and elder persons, and preventing its recurrence.

Summary of Findings:

Agency Response:

u Reviews of 47 counties performed by DHR's Response due April 12, 2001.
Evaluation and Reporting Section determined that APS staff are responding to allegations of abuse, neglect, and exploitation within 10 days for more than 90% of the cases evaluated.

u The Program does not maintain the data necessary Response due April 12, 2001.
to determine if adult protective services are being effectively delivered. However, as discussed in subsequent findings, the evaluation team did make observations indicating effectiveness problems.

u The Program does not have adequate information to Response due April 12, 2001.
determine if APS staff levels in counties are appropriate. An analysis of available information by the evaluation team indicated that some counties appeared to have extremely high caseloads while other counties had low caseloads indicating that they may not be appropriately staffed.

u The lack of APS specialized case managers and Response due April 12, 2001.
inadequate training of APS staff contributes to varying levels of service delivery throughout the state.

u Case managers at the county level who do not work Response due April 12, 2001.
fulltime on APS and a lack of APS management at the state level contribute to varying levels of service delivery throughout the state.

u Overall, the Program coordinates well with Response due April 12, 2001.
programs responsible for investigating A/N/E in long-term care facilities. However, the Program needs to identify and evaluate all open cases in long-term care facilities that do not involve guardianship or representative payeeship to determine if these cases should remain open.

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Indigent Care Trust Fund
Evaluated: December 2000 by the Department of Audits and Accounts

The purpose of the federal Disproportionate Share Hospital (DSH) Program and Georgia's Indigent Care Trust Fund (ICTF) is to provide compensation to qualifying hospitals for services provided without charge or for a reduced charge to Medicaid and medically indigent patients. Two additional purposes of the ICTF are to provide primary health care programs for the medically indigent citizens and children of Georgia, and to expand Medicaid eligibility and services.

Summary of Findings:

Agency Response:

u DCH has taken steps to improve ICTF Response due April 26, 2001.
administration. Proposed changes should increase oversight of the use of ICTF funds and continue to improve program administration.

u DCH has begun work to ensure that hospitals are Response due April 26, 2001.
complying with their primary care plans.

u Coordination of the hospitals' primary care plans Response due April 26, 2001.
with other state programs is accomplished primarily at the local level with limited direction from DCH.

u ICTF participating hospitals are required to provide Response due April 26, 2001.
effective notification of their participation in the ICTF to the public and to inform DCH of how the notification will be accomplished. DCH is working to ensure hospitals' compliance with the requirement.

u Health studies directly relating to the impact of the Response due April 26, 2001.
ICTF on the health care of indigents were not found.

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1999 Evaluation List

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Status Report for the 1999 Evaluation List

Title Access to Primary Care Services

Assigned to Audits

Status of Report A summary follows this page.

Indigent and Uncompensated Care
Public Water Systems' Drinking Water Quality Public Well-Being through Public Health and Pollution Reduction Air Quality and Emission/Commuter Reduction Strategies

Audits

A summary follows this page.

Audits

A summary follows this page.

BROC Research Audits

Annual Strategic Planning Conference held at the GWCC on 1/07/99 See the 1999 BROC Annual Report.

Sufficiency of the Hazardous Waste Trust Fund

Audits

See the 1999 BROC Annual Report

Operations of the Community Based Mental Health, Mental Retardation, and Substance Abuse Programs (DHR) and Community Mental Health Services Programs (DMA) Childhood Care & Education Joint Study Committee of Appropriations and BROC Commuter Rail
Fiber Optic Telecommunications Access in Rural Georgia Veterans Memorial State Park Conference Center and Retreat Information Requested A Requested Review of Specific Business Practice within the Division of Administration and Finance (Georgia Tech.) Grant-in-Aid

Audits
BROC Research House Research Senate Research BROC Research BROC Research BROC Research
Audits
OPB

See the BROC Research Office for a copy of this audit report.
See the BROC Research Office for a copy of this committee report.
See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter. See the BROC Research Office for a copy of this letter.
See the BROC Research Office for a copy of this performance audit report.
This report was cancelled by OPB.

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Access to Primary Care Services
Evaluated: December 1999 by the Department of Audits and Accounts
The overall purpose of the State Office of Primary Care [Department of Community Health] is to improve the availability and accessibility of primary care services in rural and medically underserved areas in Georgia.

Summary of Findings:

Agency Response:

u I The Office has not been effective in achieving its overall purpose of increasing the accessibility and availability of primary care services in rural underserved areas of the state. While the total number of physicians has increased in Georgia, the growth has not been evenly distributed throughout the state, with some counties actually experiencing a decrease in the number of primary care physicians. Only 14 (36%) of the 39 counties targeted by the Office had an increase in the number of primary care physicians from 1994 through 1998, with 15 (38%) experiencing a decrease. The Office selected these counties for targeted assistance because they have higher rates of infant mortality, death from cancer and cardiovascular disease, low birth weight babies, and percentage of population above age 65 and below 200% of the federal poverty level. Addressed in Item I (a) (b) (c) (d) (e) and (f)

I(a) The Department has developed incentive payments to rural hospitals to obtain critical access designation. Incentive payments are being made through the State Health Benefit Plan (SHBP)/Board of Regents (BOR) Plan hospital outpatient payments under both the indemnity and PPO plans. Furthermore, the Division of Medical Assistance will begin providing incentive payments to hospitals seeking CAH designations on July 1, 2000. As part of the incentive payment, CAH hospitals are required to enter into partnerships with the local public health department, community health centers, rural health centers, and federally qualified health centers. CAH designated hospitals will also be required to meet federal requirements for participation as well s state-based reporting requirements, including the impact on emergency room visits, primary care visits, and case management services for high risk populations. Preliminary evaluation data should begin to be available July 2001. Addresses Item I

u II The Office should be held accountable for meeting specific objectives that are in line with its overall purpose. Although objectives have been established for the Office, little or no action has been taken to demonstrate progress in meeting the Office's objectives. Addressed in Item I(c)

I(b) The Department is currently collecting benchmark data and will begin implementing on July 1, 2000; a resident funding formula that rewards medical schools for the placement of targeted family practice physicians, including pediatric and geriatric trained physicians, in underserved communities. DCH will require that critical access hospitals develop partnerships with medical schools to further facilitate the outplacement/training of medical students. The FY2001 budget provides $90,000 to fund preventive, occupational and environmental medicine positions. Incentives will be developed to address these additional positions as well. Addresses Items I, IV, V and VIII

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Access to Primary Care Services (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u III The Office should take steps to more effectively I(c) The Department has been charged with

assist rural and medically underserved

developing a proposal to address Georgia's

communities with their primary care access

uninsured. As part of this process the Department

problems. Currently, the Office does not conduct

will be developing recommendations regarding the

individual need assessments to understand the

coordination/streamlining of existing state-funded

scope of the access problems in the communities it

safety net programs that provide access to health

identifies for intervention. As a result, the Office

care services in rural areas of the state. The

does not have a way to effectively match available

Department's recommendations will be presented

resources with the specific kinds of access problems

to the Governor and DCH board in August 2000.

that exist. Addressed in I(e), III(a), III(b) and

Addresses Items I and II

III(c)

I(d) The Department serves as the coordinating

agency for the Community Access Grant program.

The primary objective is to ensure that local and

regional entities requesting HRSA grant funding

for the development of systems/networks of care

are coordinated with other potential granters and

state

policy directors. Furthermore, the objective is to

develop networks of care that include all existing

health care providers (e.g. hospitals, medical

schools, community health centers, rural health

care centers, federally qualified health centers).

Addresses Item I

u IV The state does not have a coordinated and targeted approach to effectively address the maldistribution of primary care physicians. Although the state has established six state initiatives designed to locate physicians in rural and underserved areas, the number of counties identified as rural or underserved is too large to have a significant impact.
u V Action should be taken to promote mid-level health care professionals as an effective alternative for improving primary care access in rural and underserved areas. Although the purpose of the 1972 Physician's Assistant Act was to alleviate the growing shortage and geographic distribution of health care services in the state, only 23% of physician's assistants are located in the state's rural counties. Similarly only 28% of nurse practitioners and nurse midwives are located in the state's rural counties. Addressed in Item I (b)

I(e) The Department is serving as the lead agency in the state for HRSA's campaign for 100% Access and 0 Health Disparities, 100 percent access to primary health care services and zero disparities in health status by 2010. Under this program, DCH will be working with health care providers to ensure that every person in every underserved community will have access to health care services and that there will be no disparities in health status related to race, ethnicity, gender or income. Addresses Items I and III
I(f) The Department is pursuing a HRSA State Planning grant to assist in the identification of uninsured in Georgia. Such a database in coordination with other data sources such as the CDC Behavioral Risk Factors Assessment Scale and Public Health's Claritas database, will assist in the identification of underserved areas of the state and permit the development of policies, programs, and fundraising to target these populations. Addresses Items I and VIII

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Access to Primary Care Services (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u VI The Office should revise its methodology for II Addressed in Item I(c)

identifying priority counties for intervention.

Specifically, the Office should consider a regional III(a) The Department is revising the policies and

approach to assessing primary care needs and

procedures relating to the 15% primary care

targeting efforts. In addition, it should consider

amount that eligible hospitals must spend out of

primary care resources in its process of identifying

their DSH allotments. Under the recently

need, and set benchmarks for identifying counties

approved ICTF rules changes, facilities must use

that fall below an acceptable level.

no less than 15% of the trust fund payment for

u VII The Office should review its allocation of

support of primary care services, defined as services which prevent, provide diagnosis and/or

funds to state Primary Care Centers. As discussed

initial treatment of injury, disability or illness and

in a 1992 Performance Audit, the Office continues

provide access to these services. Primary care

to fund four of five of the original centers with

also includes community health assessment and

nojustification for their location or need. In

services which are designed to improve health

addition, state funds are not equitably distributed

status and increase access to appropriate care.

among the centers.

Hospitals may elect to submit hospital specific

primary care plans. However, such plans must: 1)

address a community health need; 2) demonstrate

that DSH has evaluated needs of the community

and coordinated development of its plan with area

community and rural health centers and other

appropriate primary care providers; 3) provide

assurance that DSH gave specific consideration to

providing support for the expansion of creation of

federally qualified health centers or rural health

clinic services; and 4) identify target populations

for the proposed services. Addresses Items III and

VII

u VIII Consideration should be given to alternative strategies that have been implemented in other states to improve primary care access.

III(b) The Office of Rural Health Services (ORHS) has been reorganized into a full service office with a number of component parts. Effective October 1, 2000, the ORHS will relocate to Cordele, Georgia, which is south of Macon. A new director has been hired effective October 1 also. In addition, a Rural Health Advisory Council has been nominated to provide overall review and advice on rural health matters.

All recruitment and retention efforts of primary care providers and the rural safety net will be conducted under the ORHS. This will be in partnership with the six statewide Area Health Education Centers (AHEC), the loan scholarship programs, the academic training centers, the regional networks of health delivery, and the Rural Enrichment Access Program (REAP) from Mercer Medical School.

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Access to Primary Care Services (continued)
Evaluated: December 1999 by the Department of Audits and Accounts
It is important to note that in 1999-2000 the state of Georgia received ten rural health outreach grants from the Health Resources Service Administration (HRSA). This was the largest number of grants in the Region IV 8 southern states area.
Working in conjunction with the Division of Health Planning, the Department has finalized the 2000 Rural Health Care Plan. This document will provide the supportive data for unmet needs counties. Addresses Item III
III(c) The Department received $3.5 million in state funding in the FY 2001 budget for development of a rural health system network. These funds will be used to provide incentives to address access to health care for underserved communities as identified through a community-needs assessment process. The Department will begin making these funds available around July 1, 2000. Addresses Item III
III(d) Addressed in Item I(e)
VII(a) Addressed in Item III (a)
VII (b) The primary care staff has completed an unmet needs report which documents resources that are provided to all counties in the state. This report will be used for primary care decisions in the state's allocation of funds. The ORHS, which operates under the primary care component, has reassigned the nine nurse positions and support staff back to the Department of Human Resources (DHR) as of September 1, 2000. These are the state primary care centers that provide direct patient care through the public health district offices. Addresses Item VII
VIII(a) Addressed in Item I(b) and (f)

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Access to Primary Care Services (continued)
Evaluated: December 1999 by the Department of Audits and Accounts
VIII(b) The Department is supporting the Access
Emanuel project, an initiative based on a similar program in North Carolina, which evaluates the feasibility and effectiveness of community based networks of care. Access Emanuel has entered into partnerships with local providers including hospitals, physicians, pharmacies, and public health departments to address the needs of Emanuel County residents. Access Emanuel will be evaluating the effectiveness of access to care, as measured by reduced emergency room visits, increased primary care visits, and increases in the use of cure management for high risk populations. Preliminary measures should be available mid to end of next year. An independent evaluation of Access Emanuel will be conducted at the beginning of FY01 with a report submitted by early next year. Addresses Item VIII

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Indigent and Uncompensated Care
Evaluated: December 1999 by the Department of Audits and Accounts
The Medical College of Georgia (MCG) Hospital and Clinics (the Hospital) was established to serve as an auxiliary of the Medical College of Georgia in the development of medical knowledge and skills through organized programs and teaching.

Summary of Findings:

Agency Response:

u Action should be taken to clarify the Hospital's The report described in detail the size of the

responsibility for providing care to uninsured

indigent care problem at MCG and the impact of

Georgians. Given the recent change in health care,

unfunded care on the financial stability of the

the Hospital can no longer afford to shift the cost of

Hospital and Clinics. Both the BROC report and

uncompensated care from uninsured patients onto

the Board of Regents Blue Ribbon Commission

insured patients. Reductions in the Hospital's usual

report urged efforts to address the problem of

sources of revenue have made it increasingly

indigent care at the MCG H&C. In addition, with

difficult to continue to absorb approximately $42.1

the transition of the Hospital and Clinics to

million in uncompensated care costs generated by

operation under MCG Health, Inc. effective July 1,

uninsured patients each year.

2000, the Board of MCG Health is seeking

strategies to improve the management of indigent

care.

Our recommended plan of action to address the findings of the report include the following steps:
a. Develop a set of plans, which foster increasing access to quality primary care in local communities close to the patient's home. Already the MCG H&C/MCG Health, Inc. is working with multiple entities to develop such plans through the Department of Community Health (DCH) and its Indigent Care Trust Fund Primary Care Plan. Dollars have been allocated for this past fiscal year (1999-2000) and will be allocated for each year that the program continues to exist.
b. The MCG H&C policy on the acceptance of patients is being revised. It is expected that reasonable limitations on acceptance of uninsured patients will be incorporated in the policy. For example, patients who require services which are "readily" available in their home community, such as treatment of fractures, routine office procedures, transfusions, etc., would not be normally referred to the College's clinical operations simply because the individual lacked insurance. Most uninsured patients are tax paying,

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Indigent and Uncompensated Care (continued)
Evaluated: December 1999 by the Department of Audits and Accounts
working citizens who are locked out of the health insurance market for one reason or another. It is expected that local communities working with local physicians and their associated disproportionate share hospitals that receive ICTF payments will work towards providing locally accessible care to their citizens. Many communities in Georgia are working in collaborative efforts to make needed care available locally. The MCG H&C will work to support these efforts by local communities. The revised policy and protocols will be completed by December 31, 2000.
Likewise, the MCG H&C would want to make its true tertiary and quaternary services, not otherwise available consideration to the patient's insured status.
c. The MCG H&C recommends that the State of Georgia, through an appropriate research method, analyze the role of physicians in delivering care to the uninsured throughout the state. As managed care and other governmental reimbursement pressures have increased, physicians have less time to devote to caring for those who lack the ability to pay. The problem needs to be much better understood before it can be addressed.
d. Finally, the MCG H&C through MCG Health, Inc. intends to continue to work collaboratively, both locally and at the state level as well as with federal legislative and policy leaders, on macro solutions to the growing problem of increasing numbers of uninsured persons. It is recommended that support be given to statewide initiatives which are likely to positively impact this problem, such as expansion of Medicaid and Peachcare eligibility, small employer access to large group rates, and other insurance reform measures.

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2000 Annual Report
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Indigent and Uncompensated Care (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u The Hospital should establish a more manageable patient acceptance policy. Although several departments try to manage the amount of uncompensated care they provide, it is the Hospital's overall policy as a state-funded teaching hospital to serve all Georgians regardless of their ability to pay. As a result, physicians from around the state refer their uninsured patients to MCG for free or discounted care as well as for specialty care. This results in a large amount of uncompensated care for the Hospital, which, like other teaching hospitals, has a higher cost of providing care than non-teaching hospitals. According to the 1998 Comparative Performance of U.S. Hospitals, the median expense per admission in a non-teaching hospital is $4,000, compared to $4,600 for teaching hospitals and $5,200 for teaching hospitals with more than 400 beds like MCG.
An analysis of fiscal year 1998 patient data revealed that approximately 37% of all cases from 101-150 and 151-200 miles from Augusta were uninsured, while only 17% from the 50-mile Augusta area were uninsured. It is estimated that approximately $7.6 million in uninsured charges associated with treating a greater percentage of uninsured patients was shifted from local communities (outside a 50-mile radius) to the Hospital in fiscal year 1998. This was calculated by applying the percentage of uninsured cases from the Augusta area to the other areas of the state.

This finding, of course, is intertwined with the first finding regarding clarification of the Hospital's responsibility to care for the uninsured. The medical staff leaders of the MCG H&C have been engaged in a process to revise the Hospital's patient acceptance policy. Given the complexities involved, it is expected that this policy change will be adopted within the first six months of operation of the Hospital and Clinics by MCG Health, Inc. The policy considerations will include: keeping the specialized services available at the MCG H&C available to communities through the state who lack such services; keeping primary care and basic care close to the patient's home; simplifying the internal referral processes among the clinical departments at MCG and building stronger incentives for physicians and hospitals to refer both insured and uninsured patients without biased referral patterns based on the patients ability to pay.

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2000 Annual Report
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Indigent and Uncompensated Care (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u Action should be taken to develop a basis for the $34 million in state appropriations given to the Hospital. Although the Hospital has received state appropriations since it began operating in 1956, the basis for the amount has not been specified. As a result, the Hospital has felt obligated to treat all Georgians regardless of their ability to pay. The amount of state appropriation, however, is insufficient to cover the cost of the $42.1 million in uncompensated care it provides to uninsured Georgians.

With respect to the state appropriation to MCG for

hospitals and clinics, it is expected that through the

contract with MCG Health, Inc., the hospital and

clinics support mission will continue. We disagree

with the finding that the purpose of the state

appropriation should be clarified.

The

appropriation is clearly designated for the support

of the Hospital and Clinics, which provides patient

care in support of the education and research

missions of the institution. Georgia Code

specifically empowers the BOR to operate the

hospital in a manner consistent with its mission.

Because MCG's missions of education and patient

care are significantly intertwined, the appropriated

funds must of necessity include the following two

components:

1. Support of the hospital costs associated with the undergraduate, graduate, and specialty training programs for physicians, dentists, nurses, and allied health professionals that are so important to the future health of the citizens of the state. This support is vital to preserving the teaching hospital's function as a dynamic, contemporary, and excellent learning "laboratory" for future health care professionals.

2. Support of the direct costs of clinical care for uninsured patients at the MCG H&C that should be fully covered. Not to cover these costs creates the potential that the costs will be subsidized by funds intended for educational purposes.

Thus, we feel it is reasonable that the annual state appropriation to the Medical College of Georgia Hospital and Clinics should cover the full costs of hospital and clinic based teaching activities that are not otherwise reimbursed, as well as the direct costs of care to uninsured patients.

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2000 Annual Report
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Indigent and Uncompensated Care (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u The Hospital should be commended for identifying Under the contract with MCG Health, Inc.,

strategies to reduce its costs and increase its

Hospital and Clinic administrators continue to

revenues. Although the Hospital originally

implement action steps, which are decreasing its

projected a budget deficit of $22.5 million for fiscal

costs, and enhancing revenue. As an example, the

year 2000 (due to increasing personnel costs and

pharmacy outpatient reorganization has stopped

reduced revenues), it has implemented or plans to

the 42% per year growth in expenses and for fiscal

implement a variety of stabilization initiatives that

year 2000 resulted in $1.6 million in savings. With

will allow it to balance its budget.

the transition to MCG Health, Inc., these initiatives

will continue.

u The Hospital should review the effectiveness of its As a tertiary/quaternary academic medical center

current policy for admitting out-of-state patients.

with unique capabilities, the Medical College of

Based on recent data available regarding South

Georgia Hospital and Clinics attracts patients from

Carolina patients, the Hospital does not appear to

a multi-state service area. With its location in

be fully compensated for the care it provides to out-

Augusta just a few blocks from the Savannah River,

of-state patients. Approximately 70% ($9.9

the medical center draws 13% of its total patients

million) of charges generated by uninsured and

from South Carolina. These patients are critical to

Medicaid patients from South Carolina were

the Medical College of Georgia discharging its tri-

uncollected in fiscal year 1997.

partite mission of patient care, education, and

research. With a balanced payer mix, this

geographic component is also critical to the fiscal

health of our system as well.

The MCG Hospital and Clinics has had in force a policy that requires all South Carolina self pay patients to pay full charges and requires a deposit at the time of admission for elective admission patients. However, a significant percentage of patients entering the system arrive through the Emergency Departments where the hospital is obligated under federal law (COBRA and EMTALA) to assess and stabilize.
The MCG Hospital and Clinics in all cases reports bad debt (the difference between charges and reimbursement) to South Carolina as indigent and charity care and receives partial payment through the South Carolina Disproportionate Share Hospitals (DSH) program. With the transition of the MCG Hospital and Clinics to MCG Health, Inc., the organization will continue to enforce the aforementioned policy, monitor its effectiveness, and make modifications where necessary. Additionally, the development of a more manageable patient acceptance policy within the first six (6) months will have universal application and should reduce the volume of inappropriate referrals coming to the health system from South Carolina as well as Georgia.

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2000 Annual Report
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Indigent and Uncompensated Care (continued)
Evaluated: December 1999 by the Department of Audits and Accounts

u MCG should better monitor its faculty affiliations with community hospitals and health centers to ensure that they are meeting their intended objectives. Currently, data regarding physician affiliations is decentralized among individual clinical departments at MCG, community hospitals and health centers, and the Physicians Practice group. As a result, complete information could not be obtained to evaluate whether these affiliations strengthen the financial base of the institution, broaden the experience of students, or provide services to a broad group of citizens, including those who are not medically indigent.

With the transition to MCG Health, Inc., the responsibility for operation of off-site clinical services will be transferred to the new health system. An inventory of all existing arrangements by the clinical department with local doctors, hospitals, clinics, or state agencies has been completed. Policies governing off-site practices will be established including monitoring the activities of these outreach programs and evaluation of their effectiveness in achieving the objectives of the College. This will be completed by December 31, 2000.

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2000 Annual Report
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Public Water Systems' Drinking Water Quality
Evaluated: June 2000 by the Department of Audits and Accounts

The majority of Georgians (estimated to be more than 6.6 million or 85% of the state's population) get their drinking water from the 2,600 public water systems regulated under the federal Safe Drinking Water Act. This Act directs the U.S. Environmental Protection Agency (EPA) to ensure that public water systems (systems serving more than 25 people) meet minimum standards limiting the levels of specific contaminants that can adversely affect the public. The Act also requires public water systems to monitor the water delivered to consumers to determine if it meets these standards. The EPA has granted the Department of Natural Resources' Environmental Protection Division (EPD) the primary responsibility for enforcing these standards and for overseeing public water systems in Georgia.

Summary of Findings:

Agency Response:

u Trend data indicates that Georgia's drinking water quality is relatively good with approximately 94% to 95% of the state's public water systems having no reported violations of federal Maximum Contaminant Level (MCL) standards during the last four years. On the other hand, the public water systems in Georgia need to improve their compliance with federal reporting standards. Federal data indicated that about 27% of Georgia's systems had significant reporting violations during fiscal year 1997 as compared to a national average of 17%. (More recent data is not available.)

No response

u Less than five percent of the public water systems in Georgia were listed as Significant NonCompliers (SNCs) by the U.S. EPA for calendar year 1999. Most of these systems were listed as SNCs because of reporting/monitoring violations rather than sustained high levels of contaminants in drinking water. A review of the 111 public water systems identified as SNCs during the 1999 fiscal year did not identify any significant geographic clusters.

Due to the many problems associated with the old federal data reporting system called the Safe Drinking Water Information System (SDWIS/Fed), EPA is currently working on a strategic plan to develop a new data system. EPA strongly confirms continued support of the SDWIS/State system and is considering replacing SDWIS/Fed with SDWIS/State.

u The Drinking Water Compliance Program is taking action to bring water systems that have been classified as Significant Non-Compliers (SNCs) by the U.S. Environmental Protection Agency back into compliance. The Program should also continue in its efforts to develop additional mechanisms to help prevent the violations that result in the water systems being classified as SNCs.

The Division upgraded to version 6.1 of SDWIS/State in August 2000 and is currently using the Inventory Business System, Legal Entity Business System, TCR Business System and the Enforcement Business System. We are currently migrating chemical data, monitoring schedules and violations from the old data system into SDWIS/State. By December 31,2000, SDWIS/State 6.1 will be installed in each Regional office. The Regional associates will then be able to view inventory data, TCR data and violation tracking.

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2000 Annual Report
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Public Water Systems' Drinking Water Quality (continued)
Evaluated: June 2000 by the Department of Audits and Accounts

Version 7.0 of SDWIS/State is scheduled for release in December of 2000. Version 7.0 includes a Compliance Assistance Business System and an improved Enforcement Business System. The compliance assistance module will include all of the current regulations up through December 1999. After Version 7.0 is installed and in operation, Regional and Drinking Water associates will be scheduled for training.

u The Drinking Water compliance Program needs to continue its efforts to improve its data systems. Improvements are needed in the accuracy of data maintained in the Program's files and records, in data maintained in the Program's State Database, and in data provided by the Program to the U.S. EPA.

The Division will continue to its efforts to improve the data systems and will upgrade as new releases of SDWIS/State are released. We have also set aside funding during Federal FY2001 for the development of a web interface to SDWIS/State for use by the regional offices and the general public. Implementation of SDWIS/State in the regional offices will improve communications between the Drinking Water Programs and the regional offices. Also, we propose that key Drinking Water Program associates attend the monthly regional managers meetings to further foster communications and team efforts.

The paper files located in the Atlanta office are the file of record and need improvement. The managers for the Drinking Water Programs will set up a team to evaluate the filing system and make recommendations for improvement by December 31, 2000.

u Verification of what is essentially self-reported Based on our lab capacity and information

water sampling submissions should be considered.

gathered during sanitary surveys, the Division

considers randomly sampling of drinking water

quality as warranted. The managers for the

Drinking Water Programs will establish a team

with the Division laboratory managers to make

recommendations by July 31,2001.

u The Drinking water Compliance Program should improve communication and coordination with EPD Regional Office personnel performing drinking water activities who do not report directly to the Program.

With the compliance assistance and improved enforcement business systems in Version 7.0 of SDWIS/State, the Division will be able to more accurately track drinking water system compliance and take timely enforcement before the system becomes a Significant Non-complier (SNC).

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2000 Annual Report
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Public Water Systems' Drinking Water Quality (continued)
Evaluated: June 2000 by the Department of Audits and Accounts

Also, after the monitoring schedules are migrated into SDWIS/State, each water system will be sent a schedule to help remind them o f monitoring requirements and monitoring frequencies. The sample schedules should help reduce the monitoring and reporting violations related to chemical monitoring and will be distributed by December 31, 2001.

u A review of the duties and responsibilities of the state programs, federal agencies, and statewide associations involved with drinking water quality, identified little potential for the state programs providing services that duplicated the efforts of other programs/entities.

No response.

u While the quality of drinking water provided by

Georgia's public water systems has been good in

recent years, this does not guarantee that the State

will always have an abundant supply of safe

drinking waters.

Various agencies and

organizations are working on minimizing

contamination of the State's drinking water sources

and ensuring an adequate supply of drinking water

in the future.

No response.

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The joint Budgetary Responsibility Oversight Committee evaluates itself in light of its own
Vision, Mission, and Beliefs:

Vision Mission

The Budgetary Responsibility Oversight Committee shall be the principal state policy/program review arm of the Georgia General Assembly, measuring policy/program performance against commonsense standards of efficiency while comparing policy/program goals with legislative intent.
The mission of the Budgetary Responsibility Oversight Committee is to follow the intent of the General Assembly that taxpayer dollars be spent in the most effective and efficient manner possible. We will recommend that the General Assembly deny resources to unworthy or redundant programs. We will recommend improvements for worthy programs to allow them to become effective and efficient. We will, further, advise the General Assembly whether the strategic plans of individual agencies are consistent with the intent of the legislature and with the state strategic plan.

Beliefs

The members of the Budgetary Responsibility Oversight Committee believe that . . .
1. The General Assembly has the responsibility to decide which, out of the many needs and wants of human existence, are the appropriate public policy issues to be addressed by legislation and the expenditure of tax dollars.
2. Legislative responsibility properly pertains to the recognition of a social problem to be addressed by state action. Such legislative responsibility is not discharged merely by funding well-intentioned programs, but includes oversight of the programs themselves through evaluations of their functions and performance.
3. Public policies recognized as properly in the domain of government intervention should be addressed in a coordinated manner by relevant state agencies.
4. The people of Georgia deserve assurance that their elected representatives are engaged in an ongoing review of expenditures by state agencies.
5. A vigilant effort to determine if tax money is actually being put to use according to legislative intent is the proper duty of the Budgetary Responsibility Oversight Committee.
6. Sound advice based on objective and impartial research is the product we are constituted to give to the General Assembly of the State of Georgia.