Report 2010-103R All Recommendation Responses

Report 2010-103R: Department of Public Health: It Faces Significant Fiscal Challenges and Lacks Transparency in Its Administration of the Every Woman Counts Program (Release Date: July 2010)

Recommendation #1 To: Health Care Services, Department of

To the extent that Public Health continues to fund its various contracts, it should establish clearer expectations with its contractors concerning how much money is to be spent directly on the different aspects of the EWC program and should monitor spending to confirm that these expectations are being met.

Annual Follow-Up Agency Response From October 2016

Will not implement

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2015

Will not implement

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2014

Will Not Implement

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From November 2013

EWC believes its current practice is adequate for monitoring contract activities and spending. See Exhibit A - Scope of Work, Santa Barbara County Public Health Department; Contract #12-89329 (Attachment 1). Contractors are required to submit a biannual Progress Report detailing their progress in meeting Scope of Work objectives. See Regional Contractor Progress Report Checklist, Santa Barbara County Public Health Department; Contract #12-89329 (Attachment 2). All invoices are required to include full supporting documentation for expenses charged. Additional monitoring is not required to confirm that contract expectations are being met.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2012

EWC believes its current practice is adequate for monitoring contract activities and spending. Contractor activities are tied to the salaries of staff performing the duties plus associated operating costs. For contract regional coordinators, "provider network duties" and "provider site reviews" are performed by nurse clinical coordinators. Tailored health education is performed by health educators. These classifications are funded in the personnel line-item and can be seen in budget and invoice detail. Clinical coordinators are assigned specific numbers of site reviews to conduct each fiscal year in accordance with the funded FTE (30 site visits per 1 FTE). Similarly, health educators are assigned specific numbers of women to reach through tailored health education each fiscal year. Progress for each deliverable is reported biannually. Contractors provide documentation for all activities and expenses invoiced during annual site reviews. EWC staff continuously track, monitor and verify that all SOW deliverables have been completed each FY and that invoices can be adjusted if the contractors fail to perform part or all of a specific deliverable.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Recommendation #2 To: Health Care Services, Department of

To ensure better public transparency and accountability for how the EWC program is administered, Public Health should comply with state law to develop regulations, based on input from the public and interested parties, that will direct how Public Health administers the EWC program. At a minimum, such regulations should define the eligibility criteria for women seeking access to EWC screening services.

Annual Follow-Up Agency Response From October 2016

At this time, DHCS, EWC program continues to cooperate with DHCS Office of Legal Services to appropriately review procedural requirements for developing EWC Regulation Package DHCS 12-006E. Program refers to their Breast and Cervical Cancer Advisory Council on specific substantive rules essential to ensuring public health, safety, and the general welfare of California's women. Corresponding with the Administrative Procedure Act (APA), EWC continues to integrate the APA Emergency Regulation provisions. Program has completed major steps towards adding the required documentation to the regulation package. However, EWC has not completed the regulation package yet due to major revision of the entire package we prepared last year. We have revised each proposed regulation section, including the provider enrollment forms, clinical guidance sections, and eligibility requirements to conform to the CDC and National Breast and Cervical Cancer Screening provisions and current Affordable Care Act policies.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Annual Follow-Up Agency Response From October 2015

No update

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Annual Follow-Up Agency Response From October 2014

At this time, the Department of Health Care Services (DHCS), EWC program continues to cooperate with DHCS Office of Regulations and Office of Legal Services to appropriately review procedural requirements, for developing EWC Regulation Package DHCS-12-006E. Program refers to their Breast and Cervical Cancer Advisory Council on specific substantive rules essential to ensuring public health, safety, and the general welfare of California's women. Corresponding with the Administrative Procedure Act, EWC continues to integrate the APA Emergency Regulation provisions. Program has completed major steps that comprises of the required documentation to ensure promulgating regulations. A target date to implement EWC Emergency Regulations is scheduled for December 2014.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Annual Follow-Up Agency Response From November 2013

At this time, DHCS/EWC program continues to cooperate with DHCS Office of Regulations and Office of Legal Services to appropriately review procedural requirements, for developing regulation package DHCS-12-006E. See DHCS 2013-Rule Making Calendar (Attachment 1). A target date to implement EWC Emergency Regulations is scheduled for September 2014. See attached EWC Regulations Timeline (Attachment 2). EWC consults with the Breast and Cervical Cancer Advisory Council (BCCAC) on specific substantive rules essential to ensuring public health, safety, and the general welfare of California's women. See the December 5, 2012, EWC Regulations Review Webinar PowerPoint Presentation (Attachment 3) and December 2012 Draft Regulations Text (Attachment 4) that was presented to BCCAC members and EWC stakeholders. Corresponding with the Administrative Procedure Act, EWC continues to integrate step-by-step Emergency Regulation provisions. Program has completed major steps that comprise researching, evaluating program authority and standards, and other required documentation to ensure promulgating regulations. EWC respectfully submits the July 2013 Draft Regulations Text (Attachment 5) and Draft Initial Statement of Reasons (Attachment 6) as evidence of progress towards promulgation of program regulations.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Annual Follow-Up Agency Response From October 2012

At this time, the Department of Health Care Services (DHCS), EWC program is intently collaborating with the DHCS Office of Regulations and Office of Legal Services to develop regulation package DHCS-12-006E (Please note: Effective July 1, 2012 EWC formally transitioned to DHCS). EWC is determining what specific substantive rules are necessary to ensure public health, safety and general welfare of California's women. Program is following a specific DHCS step-by-step Emergency Regulation process. In addition, EWC is researching and evaluating program authority, standards, and other reference documentation necessary for promulgating regulations. A target date to implement EWC Emergency Regulations is scheduled for June of 2013. Currently, draft regulation articles are not available for public comment, and a date has not yet been determined.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Recommendation #3 To: Public Health, Department of

To ensure that Public Health maximizes its use of available funding for breast cancer screening services, it should evaluate each of the EWC program’s existing contracts to determine whether the funds spent on nonclinical activities are a better use of taxpayer money than paying for a woman’s breast or cervical cancer screening.

1-Year Agency Response

Public Health provided members of the Legislature with a briefing on the EWC program on November 5, 2010. During that briefing, Public Health reported that it had renegotiated its contracts with many of the regional centers that had previously provided support services to the EWC program. The result of these renegotiations often reduced the total amounts to be paid to these contractors. For example, Table 4 of our audit report shows that the contract amounts for these regional centers, which expired on June 30, 2010, varied between $332,000 and $489,000 per year. In its November 2010 briefing, Public Health informed members of the Legislature that the budgeted amounts for each of these contracts for fiscal year 2010–11 had been reduced to roughly $200,000 per year. In its one-year response to the audit, Public Health reported that it has completed its review of the EWC program’s remaining contracts and has reduced the funds committed to one of its contracts with the San Diego State University Research Foundation by nearly 50 percent. (2012-406, p. 84).

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Recommendation #4 To: Public Health, Department of

To ensure that Public Health can maintain fiscal control over the EWC program, we recommend that it develop budgets for the EWC program that clearly communicate to the Legislature the level of service that it can provide based on available resources. One way Public Health could do this would be to estimate the number of women that can be screened at different levels of funding.

1-Year Agency Response

In its one-year response, Public Health indicated that it had developed a formal budget estimate package for the EWC program that was included in the Governor’s Budget for fiscal year 2011–12. This package contained the estimated number of women served based on its projection of the amount of clinical claims the EWC program would pay during the fiscal year. We reviewed the formal budget estimate package that Public Health provided to the Legislature as part of the fiscal year 2011–12 budget process and confirmed that it provided the Legislature with information on the expected number of women to be served. We also noted that Public Health has posted its estimate packages on the EWC program’s Web site. Public Health’s one-year response also indicated that it is attempting to track the social security numbers of the women who access the EWC program in an effort to better track caseload. (2012-406, p. 84).

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Recommendation #5 To: Public Health, Department of

To ensure that Public Health can maintain fiscal control over the EWC program, we recommend that it seek legislation or other guidance from the Legislature to define actions the program may take to ensure that spending stays within amounts appropriated for a fiscal year.

1-Year Agency Response

Public Health’s one-year response to this recommendation focused on its efforts to develop and promulgate regulations that will direct its future administration of the EWC program, and discussed its efforts to develop a formal caseload estimation process as a tool to better communicate to the Legislature the affect of proposed appropriations. Legislative Action: Legislation enacted. Chapter 717, Statutes of 2010 (Senate Bill 853), requires Public Health to provide the Legislature with quarterly updates on caseload, estimated expenditures, and related program monitoring data for the EWC program. Moreover, Assembly Bill 1640 of the 2009–10 Regular Legislative Session would have, among other things, required Public Health to notify the Legislature at least 90 days prior to changing EWC eligibility requirements. However, the governor vetoed this bill on September 29, 2010 (2012-406, p. 85).

California State Auditor's Assessment of 1-Year Status: Fully Implemented

Recommendation #6 To: Public Health, Department of

To ensure better public transparency and accountability for how the EWC program is administered, Public Health should provide the Legislature and the public with a time frame indicating when Public Health will issue its annual report on the effectiveness of the EWC program. Further, Public Health should inform the Legislature and the public of the steps it is taking to continue to comply with the annual reporting requirement in the future.

1-Year Agency Response

Although Public Health acknowledged in its one-year response that it had not submitted its annual report to the Legislature regarding the effectiveness of the EWC program, we noted that it released its report on June 21, 2011. The report is available on Public Health’s Web site under the EWC program’s web page. According to the annual report, Public Health anticipates releasing its next report on the EWC program’s effectiveness in February 2012. (2012-406, p. 85).

California State Auditor's Assessment of 1-Year Status: Fully Implemented

All Recommendations in 2010-103R

Agency responses received after June 2013 are posted verbatim.