My immediate comments about today's workshop while watching via LIVE video

I wrote these comments live as I watched the March 4th, 2019 Lake County School Board workshop meeting video.

The 3+ hour workshop covered two main topics:
- Review of the Altoona charter school renewal and issues.
- Update by the staff of the "Care Here Wellness Centers" about the costs and operations of the four FREE LCSD employee clinics they manage.  

I started mid-way through the Altoona charter school presentation:

The March 4th workshop agenda and powerpoints are on the Board Docs site HERE.

The 3+ hour video should soon be on the YouTube channel HERE!

- Good idea to use the picture in picture video feature, but LCSD needs standards for presentations to STOP using tiny text that is unreadable. Also, maximize the slide for readability and move the picture of talking people into a corner.

- Can someone just give Attorney Johnson a lavalier or headphone mic because he constantly forgets to use the one there? I would hate to miss his shared wisdom. Make that a requirement in his contract.

- Watching the grilling of this small charter, I am reminded of when I audited 40+ manufacturing plants. It was clear the small plants didn't have the staff to do all the requirements set by the parent company and we came up with minimal standards and tracking for small plants to reduce bureaucratic overload. However, we then had a manager of a small plant was able to fraudulently siphon off $80k because the Controller was too lenient. If State requirements are forcing this, add that to legislative objectives to reduce bureaucratic requirements. Or, if staff REALLY believes all the requirements should stay, stop approving small charters. One or the other. 

- I thought the point of the Charter rep made of lack of communications with staff except for renewal times had merit. Is this a staff funding issue to not have an outreach facilitator?

- However, it sounds like they are skipping sound financial controls to fund operations, and that should not be skipped. Isn't their board competent in demanding proper financials? Especially if they are skipping red book requirements.

- One of the problems with government fund accounting and CAFR's is that there is no required statement of cash flow like a business, thus hard to determine uses, sources, and projections of cash flow. Budgets don't cover all finances. This is coming out in a national review of CAFR's by a taxpayer advocacy group.

- Did I hear correctly that the rep didn't get confirmed delivery of the issues and he was expected to know they were on Board Docs? Need a process to confirm audited Charters actually get all info in time to react and prepare. 

- Good to hear they are now going to monitor progress annually. Stephanie made good points on this.

- Kudos to Julie Summerlin for not running off in the wilderness with all the required monitoring of charters.

- It is not clear whether the Altoona rep didn't take this seriously or just didn't get info early enough to prepare. Procedures need to change so that reps like this arrive prepared. Staff always is prepared, so invited speakers need to be qualified to ensure they understand to be prepared. Board member Mathias's comments that responses sb submitted first to Board in writing so they could respond with questions for the Charter staff BEFORE appearance at a public meeting. Good idea.  

- Dr. Burn's comments about getting calls on charters when she has no authority is pertinent. However, you could track such calls centrally for a quarterly status report or forward them to Ms. Summerlin for tracking. LCSD could set up a method to track these complaints, not just say talk to the charter board.

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Discussion on Care Here Wellness Centers:

As a preface, since it was not explained in agenda, they are most likely due to earlier discussions on the high cost of health insurance claims and how is the $5-million investment in the employee health care clinics affecting that.  

- Kudos on having a copy of their presentation and slides in Board Docs. 

- Serves 4,092 employees.
- This is a good dashboard format and a version of LCSD operations should be part of monthly Board meetings. This firm is showing these reports for a $5-million operation and nothing similar is used for most local government, including LCSD.

- He makes the point their average cost is lower, but by making it free, it is used more by employees. However, I believe there is no employee co-pay. My experience in two corporations was that when the employee has no co-payment, they increase uthe n-needed use of services. If employee had to pay a co-pay of at least 20%, they would make cost effective decisions rather than just use it whenever anyone had a temperature.

- His cited "out of pocket" savings indicating socialism - FREE STUFF when employees have no co-pay.  

- The reason to be a teacher should not be to get free health care - require percentage contribution. Government should not be subsidizing healthcare more than private industry. Additionally, this then translates into expectations for FREE STUFF as a retiree.

- The issue of medical staff qualifications is important. If laws require higher standards than public clinics (not sure about that) it is more costly. I always went to a clinic where I always got a physician assistant, not a medical doctor. Are the clinics staff overqualified for the basic needs of a clinic. The rep says some "population" will only see a full MD... then they should pay a co-pay for that, not cost taxpayers more.

- They estimate the cost of medicines will go up 10% - well, employees should be required to pay excess over CPI increase. STOP passing on full costs to the taxpayer without the employee having some cost sharing.

- Great question from Bill Mathias about why costs haven't dropped because the idea of clinics was to SAVE money, but costs keep going up.  

- Hooray! Mathias brought up his staff has co-pays, while LCSD doesn't charge it.   

- Red flag - he said they are providing "chronic disease management" which needs to be investigated. Those usually include life style medical maladies like diabetes, cancers from smoking, etc. You need to know which are life style choices and enact aggressive programs to reduce those situations and COSTS now, or you end up paying even for retirees. Examples are people who smoke or eat badly, and you need standards to require they modify behaviors or terminate them. Don't become a provider of FREE medical for people who won't eat, act healthily. (Why do we see so many FAT people working in schools?) Why are taxpayers required to subsidize their poor behavior choices. One action could be that when an employee uses a clinic, their lifestyle effects (like obesity) are recorded and they are required to go on a mitigation program or be terminated.

- Good point by Marc Dodd. Why aren't employees using Saturdays more rather than work hours. Why not require higher co-pay for working hours to alter economic behavior. STOP the taxpayer FREE lunches!

- A discussion verified "employees pay nothing at clinics". "Are we overusing the clinic for simple issues (Mathias). AND, meds are FREE also if they have it in-house??? 

- No shows is an issue. But Board policy in 2016 set some payback, but still about 1000 no-shows. Employees are booking appointments at more than one clinic. "Board policy" for no shows is "lenient". Marc Dodd "We just can't afford to cover no shows...". THIS NEEDS TO BE FIXED. My dentist only allows on no-show, then charges full rate for others.

- High cover of chronic and acute patients. Needs to be investigated and they be terminated if they don't act to reduce the issue. (11:18)

- I hope someone is writing down every one of these cost containment issues for a workshop to change procedures to reduce costs, transfer costs of poor health behavior people to them, etc.  

- This presentation was very beneficial. Board members need to ask why they don't get similar graphic operations and financial reports from LCSD leadership. They have this in the academic tracking software, but not overall. Just think if you had these for metrics of each school, it would be eye-opening.

- A GREAT proposal from Bill Mathias for charging $25 co-pay for every visit to earn back $900k, plus tell them to use over the counter meds. This means some employees are going to the clinic, inflating costs just to get free meds like Tylenol.

- Car dealers usually have a standard charge for "consumables" like a lubricant, fasteners, rags, etc. that is part of a bill. This should be in addition to a co-pay. If they incur any need for meds, there should be a basic, standard charge to minimize tracking costs.

- I have worked in manufacturing firms that would never tolerate free services like this because they know it will be overused and employees will fail to make good economic choices.  

- Population Health management and health coaches - Wellness overview page. 400+ employees used them. Telephonic health coaching. This is good... the question is whether the employee acts upon recommendations. There needs to be a method to TRACK all such diagnosed cases, and mandate improvement actions "to read health goals". Weight, diabetes coaching is good. Good plan to require achievement of goals to keep getting supplies. But, what happens for lazy employees who don't continue coaching. There needs to be a sanction or cost penalty. "the patient may not be ready to change..." is a red flag indicating the need to terminate them. 

- The HRA (health risk assessment, and health reimubursement funds) - WHY are taxfunds used to provide incentives to be healthy. Such people need to be terminated. HRA summary page - employee participation is only 42%.  

- HOORAY! Bill Mathias asks why can't they require all employees to be required to take tests and act in programs. This needs to be acted on. (11:49)

- The Risk Movement chart is great. Shows that those participating in the HRA program improved greatly. Problem is that not many employees are in it. Those who don't act need to be penalized, sanctioned and terminated. Taxpayers don't need to pay for bad health choices.  

- "Weight is the harder needle to move" - "it takes awhile".  

- It is clear that there are a lot of good features in this program, but the Board and administration has been too lenient in policies. The Board needs to aggressively improve program policies to mandate cost sharing with co-pays, charge for no-shows, charge co-pay for meds, mandate participation and improvement in HRA tests or face termination (if not "legal" find a similar way to penalize non-improvement without providing incentives. Employment requires showing up on time, and it should also specify good health behavior as a condition of continued employment.  

- They did not discuss penalties for going to more costly ER or out of plan centers. Are employees held economically responsible for not using the most economical health care provider? Not discussed at all and that is part of the bigger picture.

- The discussion on using the Clermont facility for xrays is very important because she said employees don't want to go there. Is there a process to make employees pay the difference if they refuse to use the clinic Xray in Clermont and go to other centers? This clearly indicates lack of cost sharing results in poor economic choices for the taxpayer paid xrays.   

- The health center staff seem very oriented to containing costs, but the Board needs to step up and implement systems to force employees to cost share, and pay the difference if they don't use the lower cost clinic services or don't participate in HRA tests.  

- This is a great discussion and should be done annually.

- I saw no discussion of tracking appointments that were NOT NEEDED, and how to reduce them. They just use the total appointments to justify expansion without anyone asking strategies to reduce the need for clinic visits. This needs to change. They need to isolate low risk appointments and have strategies to eliminate them. One way is NO MORE FREE STUFF! Start co-pays now, and cost sharing on anything, and full cost charges for no shows, etc.

- This presentation is a good lesson in performance tracking and the School Administration should have a similar system with monthly updates for the Board.

- "Patient compliance" is a major issue needing improvement. If the patient doesn't follow provider requirements, then they complain to unions, etc and be demanding. Thus the clinic needs to get support for defining non-compliance and send a report to administration so they can follow up with an employee to ensure compliance, rather than leave clinic to deal with the issue.  

- Bill Mathias - obesity numbers didn't improve - thus need serious discussion to improve.  

- If set too high standards, an employee will go to own higher cost doctor. Need way to pass on higher cost to employee if they do that. My own insurance clearly states higher cost if I go to out of plan provider - why aren't schools doing that?

- Job fairs indicate some recruits come to LCSD because of Care Here. But as Bill Mathias said, why not, it is FREE!! That needs to change. LCSD needs to focus on other professional related areas to entice recruits, not promise of free health care. That entices unhealthy people who want taxpayers to fund their poor health choices. 

- I don't understand why LCSD doesn't have tracking of cases and costs - we had it in my employers in the 1990's. We only had 1800 employees, but knew exactly which cases were running costs up such as a truck driver who was in an accident and was a quadriplegic. One reason is we required such tracking reports from the insurance provider. I actually found where a poor HR manager dropped the optional cost analysis reports to save fees, and we had to get them to find lots of waste and areas for "health coaching". There is no excuse for not using such reports.

- I am starting to question the competency of LCSD in managing health costs when they didn't even start looking at pharmacy management programs until now. The risk manager needs to start being more aggressive in monitoring and managing costs. You need a skilled, cost focused manager over health insurance. I don't think you are getting that from the risk manager. Maybe outsource all responsibility for health care and insurance to the Care Here folks. They seem much more cost analysis and control focused.

- I think you need the District Auditor to review the entire $40-million health care program and look for efficiencies and needed monitoring reports.

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Board reports:

School Choice - brought up by Marc Dodd. My opinion is that LCSD could be more competitive if they came out with a strong mission statement about how they are going to reverse Common Core and all known components. They would attract students from other counties fed up with liberal indoctrination in textbooks, etc. 

Attorney Johnson talked about a case but didn't explain what the case was about, just talked to the Board. He needs to start giving an overview of any issue he discusses. I finally figured out he was talking about the Clermont charter school, but he didn't provide a clear overview. 12:40

End - great info on the clinics and the charter school review.

The board now needs to act quickly to organize the many ideas and implement them as policies LIKE REQUIRE CO-PAYS. 

Vance Jochim
352-638-3578
Tavares, FL

Lake County, FL Fiscal Watchdog blogger

FiscalRangers.com

[email protected]