actitioner services will be effective January 1, 2014. Under the default provision, initial CFs for anesthesia, surgery, radiology, and all other services transition to a single CF effective January 1, 2017, for all services other than anesthesia. A


diology, and all other services combined that transition over four years to a single CF for all services other than anesthesia. We used the structure of the default-option transition but recalculated budget-neutral CFs for the OMFS portion of the tra


he E&M visit codes. To make the change budget neutral, CMS increased the fees for E&M visits (CMS, 2009a). Our baseline impact analysis follows the Medicare pricing rules, but we examine in Chapter Six the impact of using the consultation-code RVUs.


 Appendix A compares the OMFS and Medicare ground rules for physician services.
• Appendix B contains the crosswalk from OMFS codes to 2013 CPT codes.
• Appendix C summarizes how WC-specific codes were handled in the impact analysis.
• Appendix D con


us Only Claims with Medical Data
    Code Nature of Injury All Claims (FROI) (%)
52 Strain 30.7 49 Sprain 10.7 10 Contusion 11.4 59 All other specific injuries, NOC 8.3 40 Laceration 10.6
Claims with Medical Data (%)
37.6 11.0 9.3 7.5 6.6 5.2 3.8 3.1


eopathy in the internal-medicine category to make it comparable to the WCIS.
c Specialties that we could not match in both data sets were folded into this “all other” category. In the WCIRB table, 15 percent of payments were to unknown or unclassifie


decided to treat only 50 percent of the CPT 99070 paid amounts as allowances that would be bundled under the RBRVS. We eliminated the other 50 percent from the analysis file on the assumption that it would either be paid separately using alphanumeri


physical medicine), some of which have been deleted, modified, or otherwise updated. We therefore needed to “cross-walk” the outdated OMFS CPT codes to their CPT 2013 equivalents. There were also some California-specific OMFS codes that were not in e


replaced by new CPT 29805 in our crosswalk. If the service volume for CPT 29815 was 500, we assigned CPT 29805 a volume of 500. For cases in which a single OMFS code was split into multiple codes, we had to determine how to apportion the service vol


dicare fee-schedule amounts in 2004 and 2005. These reductions remain in effect.
17
Table 3.1 Modifications Based on California Division of Workers’ Compensation Ground Rules
  Category
Surgical procedures
Bilateral surgical procedures
Co-surgeons E&


ntly, and we discuss this in a separate section. 18
Codes that were misclassified in the OMFS as clinical
 diagnostic laboratory tests were reclassified and valued at 95% of the
 allowance applicable prior to 2004.
 WC system. We discuss how we handl


hether the CPT code is included in the fee schedule and, if it is covered, whether it is separately payable (see Table 3.3).
19
The codes that always have RVUs are status codes A and T. Noncovered services are designated by status code N. Some of the


payable. The latter reports represented 19 percent of payments under CPT 99080. Because these are WC-related reports that are not Medicare-covered services, the 120-percent limitation on aggregate fees is not affected by the separate payments for th


quiring contrast media, and nuclear medicine procedures. Because we had already excluded 50 percent of supply billings from the analysis file, we did not make a further adjustment for these items. The effect is to overstate slightly understate the MA


t analysis, we assumed that the BR-allowed amounts under the RBRVS would be the same as OMFS-paid amounts and updated the paid amounts for inflation by the estimated increase in the MEI.
20 The codes that are not on the MPFS have a 1.25 CF. Using a 1


ocedure discounting
21 The OMFS does not recognize the CPT codes for disability examinations (CPT 99455 and 99456). Instead, allowances are established through the E&M visit codes with a –17 modifier or the medical-legal procedure codes. Consistent w


nces for CPT 99081 because we
46.63 43.74 51.10 45.97 28.61 27.15 38.40 39.62
 24
treat these as BR amounts that will continue to be paid under the OMFS. The denominator is the sum of the geographically adjusted RVUs for the services included in the


ffect on estimated expenditures). The actual OMFS update factors beginning in 2014 will be determined in the annual OMFS update process based on the actual MEI and budget-neutrality factors that Medicare uses in its annual update to the MPFS. As note


erence is in the CFs. Other important differences are that
(1) patient status and qualifying codes count as additional units under the OMFS but are bundled under the RBRVS and (2) the RBRVS requires reporting time in minutes, which are divided by 15


, by Type of Service
Figure 4.2 shows the distribution of total units of service across the type of service categories used in the OMFS, exclusive of anesthesia services. We have excluded anesthesia because the
29
units are not reported on a per-serv


pecialists or missing specialty codes (53%), various types of ambulatory clinics (6%), professional services billed by hospitals (6%), orthotists (5%), and pharmacy and durable medical equipment (DME) suppliers (2%).
NOTE: Because of rounding, totals


ces.
  33
have fee-schedule rates attached to the services. As a result, the percentage of MAAs that will be priced based on RVUs shown in the last column is understated. Across all procedures,
95.6 percent of allowances will be based on RVUs determi


 CFs in Labor Code §5307.1(a)(2). The last line is presented for informational purposes only and is not used in the impact analysis.
Table 4.3 Components of Budget-Neutral Conversion-Factor Calculations
      Type of Service OMFS MAA for Services Pri


scounting have been applied, including the adjustments to the PE portion of therapy services. The estimated aggregate increase in MAA based on 120 percent of the Medicare 2012 CF before accounting for inflation is 3.4 percent
⎛1−1.20⎞. ⎜⎝ 1.16 ⎟⎠
Tab


r period, total MAAs are estimated to increase 11.9 percent. The increase represents the combined effect of inflation and the transition from current OMFS payment levels to 120 percent of Medicare in 2017.
Aggregate allowances are redistributed with


ied over or not, and they inflation.
NOTE: Because of rounding, totals might not sum precisely.
Services are assigned in Table 5.2 consistently with how they are classified in the 2013 CPT codebook. For example, reports and supplies are classified as


physician fee schedule to
120 percent of the amounts payable under the Medicare payment system for comparable services. In determining the maximum reasonable fees, any services that are not covered by Medicare are to be included at the rate establish


icare be included in the calculation? For example, if an across-the-board adjustment were made to account for the higher allowances for the consultation codes, should the allowances for the services based on the federal OWCP fee schedule and other se


mounts by the aggregate allowances for the component with no geographic adjustment. The results (Table 6.2) are budget-neutral to using the locality-specific GPCI and were used for the baseline impact analysis in Chapter Five. The overall GPCI adjust


lities are outdated and do not reflect changes in demographic and local economic conditions that have taken place since the localities were last configured. In California, 14 urban counties, including San Diego, Monterey, and Sacramento, do not have


services priced BR are included in the total MAAs. As expected, the localities with higher GAF receive lower allowances using the statewide GPCI values. For example, the allowances for San Francisco increase 10.7 percent in 2014 using the locality-s


separate CFs for anesthesia, surgery, radiology, and all other services to a single CF for all services other than anesthesia, which will continue to have its own CF. The impact analysis in Chapter Five follows the structure of the default provision


 1 × applicable percentage of the CF based on the OMFS CF, e.g., 75 percent in
⎜⎝ default OMFS CF⎟⎠ 2014.
 49
Table 6.4 Impact of Alternative Transition Conversion Factors on Aggregate Allowances, by Type of Service, Relative to the Default Conversio


ysician’s bill
• of a type that is commonly furnished in physician’s offices or clinics
• furnished by the physician or by auxiliary personnel under the physician’s direct
supervision (CMS, 2012a).
Most state WC programs adopt the Medicare approach o


nphysician-Practitioner Payment Policies
    State
Medicare
Florida
Michigan
Ohio
Oregon
Tennesseee Texasf
NP
85% of physician fee schedule, 100% if billed incident to services in a physician office or clinic
85% of a physician’s allowable feea
85% o


above, the two main considerations, apart from consistency with Medicare rules and budget-neutrality requirements, are as follows:
•
• If the services furnished by nonphysician practitioners differ from the services provided by physicians (i.e., with


23.45 129.56 135.98 149.79
Proposed Allowance: 85% of Physician Allowance
Not applicable
104.93 110.12 115.58 127.32
   NOTE: Estimates are based on 2013 RVUs for CPT 99214; transition CFs updated for inflation and RVUs adjusted
by the average statew


00% of Medicare × 1.2
      2014
2017
Using Medicare Rules in 2014
Total RBRVS Amounts Using Medicare Rules in 2017
Total RBRVS Amounts at 100% in 2014
Total RBRVS Amounts at 100% in 2017
852.90
a Sum of MAA for services priced under the RBRVS only u


lled separately. Supplies or other services over and above those usually incidental to an office visit or other outpatient visit are to be billed separately under CPT 99070.
Several comments on the DWC forum were about payment for supplies. Many phys


st potential access issues
− Disadvantages
§ Higher administrative burden
§ Requires budget-neutrality adjustment
We have summarized payments for supplies under CPT 99070 in Tables 6.10, 6.11, and 6.12.
These are the total amounts paid for supplies


he costly bills that would qualify for the additional payment might be associated with surgical procedures. Of the supplies that are billed on the same day as a diagnostic or therapeutic service, surgery accounts for 10.2 percent of the supply costs


aying separately for some required reports under CPT 99081 and not for others is not readily apparent. The first report of occupational injury or illness (Form 5021) is not separately reimbursable, while progress reports (PR-2) are.
Under the MPFS, r


0.82
15.82 0.27
0.04
Treatment Under the RBRVS
OMFS rate: $4.75 each
OMFS rate: $9.50 each
Pay for WC-required reports at the OMFS rate: (6.5 1st page; 4.0 additional) × $6.15 × 0.95; bundle other reports
Pay for WC-required consultation reports and


effective January 2010, to clarify that a transfer of care occurs when a physician relinquishes responsibility for management of some or all of a patient’s problem to another physician or qualified health care professional. However, CMS was skeptica


codes. We priced these services using the published RVUs established by the AMA for these codes (which the MPFS does not recognize) and the 2014 equivalent of fully phased rates based on 1.2 times the Medicare rate. This CF is more reflective of fina


h Medicare rules and RVUs
§ Reduces opportunity for coding inconsistencies
− Disadvantages
§ Could reduce the quality of consultation reports
§ Could discourage specialties from providing consultations for WC patients
2. Use E&M visit codes only b


t usually include preoperative visits after the decision to operate is made; intraoperative services considered usual and necessary; all follow-up care days; pain management; and supplies and miscellaneous services, such as dressing changes and remov


 visit: 99212a 1 16 Outpatient visit: 99213b 2 23 Discharge management: 99238c 0.5 38
Total Minutes
Total
16 46 19
194
Intensity RVUs per Minute
0.0224 0.0224 0.0081 0.0637 0.0224
RVUs per Service
0.48 0.97 1.28
RVUs per Minute
0.0362
Work Total RVUs


ble proportion of the total time and work associated with surgical procedures in the MPFS. For the 20 surgical codes listed in Table 6.17, postsurgical E&M visits accounted for 40.7 percent, on average (median 38.3 percent), of total service time. Ne


ies billing and adds predictability in terms of payment for providers and payers. The rationale for a global period is tied to the rationale for bundled, capitated, or prospective payment generally. Given a fixed payment rate, practitioners will prov


r these visits and for WC-required reports is one approach to address this issue. In addition, it could be argued that the 1.2 multiplier provides a cushion for longer visits. Regardless of whether the visits are covered in the global fee or separate


overpay for the intraoperative time and increase total expenditures before accounting for any increases in the total number of E&M services for WC patients that might occur if the global period were eliminated.
• Global periods are the norm in paymen


data on atypical postsurgical E&M visits. − Disadvantages
§ Requires documentation when atypical services are billed separately
§ A practitioner may still avoid WC patients with complex needs if he or she does
not believe that the 1.2 multiplier is


or infusion procedure– related PADs.
WC uses a different system to determine allowable fees for most immunizations. The OMFS has RVUs for certain immunizations (including the injection fee), while others are BR. The BR allowance is the acquisition co


nd Washington) set PAD-allowable fees at AWP times a multiple (from 0.835 to 1). California uniquely adds a significant margin (10 and
40 percent for brand and generic drugs, respectively) on top of AWP. Texas pays a multiple
(125 percent) of Texas M


id separately. AWP + administration fee (90471 and 90472)
AtMCOdiscretion;generallynot covered
No mention No mention
Appears to follow Medicare, so no separate administration fee
Immunization materials payable when authorized. 90471 and 90472 payable


t for most drugs and AWP minus 5 percent for special categories of PADs. There may be some PADs that are not currently priced by Medicare. Medi-Cal pays the same as Medicare when a Medicare rate is available and uses its pharmacy rate of reimbursemen


ion service itself into another clinical service, such as an E&M visit. Medi-Cal takes an alternative approach and includes an administration fee in the ingredient payment amount.
Specific Policy Alternatives
Implementation of the RBRVS presents an o


es maximum allowed fees under the CMS PAD fee schedule and the Medi-Cal fee schedule. Allowed fees are, for the most part, similar across the two fee schedules, which reflects Medi-Cal’s recent transition to ASP-plus-6-percent pricing.
81
Table 7.2 C


edient cost in addition to the Medicare separate payments for drug administration when no other service is provided, the total allowable fees would be $1.9 million.
Table 7.3 Comparison of Official Medical Fee Schedule, Centers for Medicare & Medicai


paid when the RBRVS is implemented. The provision specifies that the AD shall adopt the RBRVS-based fee schedule “for physician services and nonphysician practitioner services, as defined by the administrative director.” Section 5307.2(a)(2)(C) provi


s made without regard to whether the surgery is on Medicare’s list of covered ASC procedures.
Under Medicare ground rules, an ASC is recognized for the limited purpose of providing ambulatory surgical services. Medicare’s payment under its ASC fee sc


roach fails and a second surgical approach (described by a different CPT code) is utilized at the same patient encounter, the two procedures are considered sequential, and only the code corresponding to the second surgical approach may be reported.
T


 judgment of physicians and coders
• claim history.
54 Not all MUE values are published online. Some are considered to be confidential by CMS and are not publicly available.
 87
Policy Considerations
The main benefit of adopting the NCCI edits is its


s included underpayments and overpayments.
56 Edits were based on CPT code guidelines, NCCI guidelines, and CMS payment rules.
 88
quarterly. It is expected, however, that the availability of commercial software and vendors should minimize these cost


ifferent components of E&M services (see Box 7.1).
57 There are some differences between the two, and CMS recommends that either one or the other be used, not both. In general, the 1997 guidelines provide more-detailed instructions.
 89
Box 7.1 Gener


ot applicable Not applicable
Pertinent Complete
    Documentation of Examination
Brief Brief
A clinical examination can also be problem focused, expanded problem focused, detailed, or comprehensive. Like with the medical history, guidelines are provi


State WC program. The Texas WC program has adopted a more generic requirement for medical records “satisfying the AMA’s requirements for use of those CPT codes.”
The CMS documentation guidelines provide a common operational definition of the CPT code


relatively small financial incentives (Damberg, 2009). In many cases, payers also accounted for only a small fraction of the targeted provider’s panel (Rosenthal and Frank, 2006). Evidence emerging from newer experiments continues to show inconsisten


data from one of the two pilot sites (representing approximately 2,700 cases treated by high-volume providers65) showed improvements on some measures but not on others. For example, the authors found that the rate of completing activity prescription


ty indicators can be grouped into three categories:
• structural indicators (e.g., adoption of health information technology [IT])
• process indicators (e.g., whether a heart-attack patient received aspirin in the ED)
• outcome indicators (e.g., mort


port submitted within x days)
• Provider writing a modified duty prescription for the patient
• Provider performing work activity assessments
• Communication between provider and employer about workers’ return to work or work
modification
  Quality S


l also need to be developed and built in. In the WC context, this could mean paying for prompt filing of the doctor’s FROI and other reports.
There are many other important considerations, such as how rewards should be structured, mechanisms for fina


OMFS uses outdated procedure codes to describe medical services. This poses an administrative burden on providers, who must maintain a separate coding system for WC patients and increases fee disputes between providers and payers over services that a


ble. For certain issues, we examined alternative policies that might be considered and separately analyzed their impact.
100
Appendix A. Comparison of the Official Medical Fee Schedule and Medicare Ground Rules
Table A.1 Comparison of the Official Me


he same specialty who belongs to the same group practice.
An established patient has received professional services within the past three years from the physician or another physician of the same specialty who belongs to the same group practice.
If a


pervision (medical direction) (modifier = 48)
Surgery
Assistant surgeon
Nonphysician surgical assistant
Co-surgeons
Multiple- or bilateral- procedure reduction
Arthroscopy
WC
(1), Code P4 (2), and Code P5 (3)
Covered separately when performed by surg


s the difference between the next-highest endoscopy and the base endoscopy.
Similar policy
   Endoscopy, multiple
Global surgical rule
103
   Ground Rule or Issue
Starred- procedure rule
Radiology
Multiple- procedure discounting
Physical medicine
Mul


s to multiple procedures. It does not apply to add- on or bundled codes.
Full payment is made for the unit or procedure with the highest PE payment. Effective April 1, 2013, the remaining procedures or units are reimbursed at 50% payment in all setti


lly not separately reimbursable include applied hot or cold packs, eye patches, injections or debridement trays, Steri-strips, needles, syringes, eye or ear trays, drapes, sterile gloves, eyewash or drops, creams (massage), fluorescein, ultrasound pa


pneumococcal, and hepatitis B vaccines.
Vaccine rates are updated annually as part of the fee-schedule update.
Medicare does not separately pay for reports. A physician may charge Medicare beneficiaries for the completion of forms (e.g., life-insuran


na Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina Lewina
OMFS Code
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995
01995


in Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin Lewin
OMFS Code
99342
99342
99342
99342
993


 Services with No 2013 Counterpart in the Current Procedural Terminology That Were Priced with No Payment Under the Resource-Based Relative Value Scale
     OMFS OMFS Description Code
99017 Preparation of specimen for transfer
99019 Single venous/cap


volume using the number-of-units variable first and filling in, as feasible, with the other two drug-volume variables. All lines paid zero were excluded from the analysis.
Table 7.2 in Chapter Seven compares MAAs from the CMS PAD fee schedule and fro


 As of June 14, 2013: http://www.medpac.gov/documents/Aug11_Methodology_RBRVS_contractor.pdf
California Department of Health Care Services, “Provider Manuals,” undated. As of July 30, 2013:
http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp
Calif


—, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non- Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 20


ica R. Schumacher, Alexandra Wright, and Maureen A. Smith, “Physician Assistants and Nurse Practitioners as a Usual Source of Care,” Journal of Rural Health, Vol. 25, No. 4, Fall 2009, pp. 407–414.
Flodgren, Gerd, Martin P. Eccles, Sasha Shepperd, An


ion, Medicare Payment to Advanced Practice Nurses and Physician Assistants: Report to the Congress, June 2002. As of July 17, 2013: http://www.medpac.gov/documents/jun02_NonPhysPay.pdf
———, Report to the Congress: Medicare Payment Policy, March 2012.


ntives in a Performance-Based Contracting System,” Health Services Research, Vol. 38, No. 2, April 2003, pp. 535–552.
184
Sox, Harold C., Jr., “Quality of Patient Care by Nurse Practitioners and Physician’s Assistants: A Ten-Year Perspective,” Annals


trategy for Quality Improvement in Health Care, March 2011.
———, Office of Inspector General, “National Quality Strategy Will Promote Better Health, Quality Care for Americans,” news release, Washington, D.C., March 21, 2011a. As of June 14, 2013:
ht


 Benefits, Santa Monica, Calif.: RAND Corporation, OP-229-CHSWC, 2008. As of June 14, 2013:
http://www.rand.org/pubs/occasional_papers/OP229.html
Young, Gary J., Mark Meterko, Howard Beckman, Errol Baker, Bert White, Karen M. Sautter, Robert Greene,


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............ xiv Elements in State Court System Governance ............................................................. xvi State- Versus County-Level Funding of Trial Court System, by State ....................... 13 Categories of Activity Included


ided valuable long-term perspectives on changes in court financing and administration in their states over time. This work should be of interest to policymakers, court administrators, and other stakeholders concerned about ensuring high levels of acc


budgeting purposes. Some basic elements, such as the operation of the trial courts and the salaries and benefits of judges, are fairly prototypical and are probably understood to be aspects of the court system (and of related costs) in every state. S


s states that permit their court systems to retain control over some portion of court-generated fee revenue from states that do not. Table S.3 summarizes findings in this area.
xiii
Table S.3. What Happens to Court System Fee Revenue in Selected Stat


ate appropriations. In 2012, however, the governor reportedly instituted a new policy forcing the trial courts to spend down most or all of the existing reserves and limiting the size of future reserves to
1 percent the annual budget allocation. Inte


ernance.
xv
Table S.4. Elements in State Court System Governance
   Governance Dimension
Central management
Micromanaged postappropriation
Locus of power
Description
Some states use a system in which a judicial council manages the administrative auth


 from one fiscal year to the next?
• How many legislative line items are there in the state X budget pertaining to the state court system?
• How does the state X’s state court system allocate and manage the funding that it receives each year?
xvi
Thi


, Kim M. Brunner, Ed Collins, and Georgene M. Vairo. Their feedback on early presentations of this work was invaluable. G. Alan Tarr, professor of political science at Rutgers University— Camden, has our appreciation for excellent feedback on an earl


and the mechanisms of providing resources for state court systems. Taken together, information on the magnitude of the cuts and the mechanisms for funding courts could be of high value to policymakers statewide. Understanding the variation in method


A series of conferences and symposia in recent years has brought together practitioners and judges in an attempt to raise awareness of the impact of reduced court funding on the delivery of judicial services. NCSC, a long-time advocate for state jud


orted and accessible data on funding are often opaque, confusing, hidden from view, or otherwise unrepresentative of the true flow of money to the courts—serves neither the interests of the judicial branch nor those of the public. Moreover, given a v


udgetary and accounting disclosures connected with their own operation, and scholars to undertake future empirical research into the ways in which varied financing schemes affect the underlying function of state courts.
The work presented in this rep


 court systems publish contain much valuable information, those reports are used for many different public purposes:
• providing access to information about the courts
• presenting the courts in a positive light
• celebrating achievements, such as ne


systems work and to let the judges offer similar comments while also providing a narrative about the effects of the crisis on court operations. Here, we were interested in two main dimensions of operations: funding and governance. The focus on fundin


 as these our interviewees described to us. In turn, these issues offer a template by which policymakers, legislators, court administrators, and judicial
4 Justice Durham is a member of the RAND Institute for Civil Justice Board of Overseers and has


elated vein, an understanding of the financing framework for the judicial branch in any given state is likely to be critical in attempting to link the service and performance of the courts to the costs associated with operating them. For all of these


rated revenue stream could offset some or all of a court system’s expenses.
In a vacuum, it is easy to imagine a state court system that collects its own revenue to cover expenditures, therefore operating in a manner analogous to that of a private bu


l separation of powers. One implication, then, is that state courts are funded in large part by revenues raised by a separate branch of government. This mechanism has the theoretical advantage of supporting broader to access to justice by tying court


s in 45 states and identified a byzantine mix of state and municipal statutes, together with court system–imposed rules, defining such fees. Fourth, all of the states appear to have some version of a constitutional bill of rights, some provisions of


y-level funding for their trial court systems. Table 2.1 and Figure 2.1 summarize related information on California, Florida, Massachusetts, Ohio, and Utah.11
9 In most (if not all) states, the trial courts represent the largest category of operation


evenues to the state to support the court system as well.
Of the states we considered in this pilot, Ohio has the court system that places strongest emphasis on county-level funding and oversight. We were broadly told that salaries, overhead expenses


me states as distinct groups of personnel and operating activities with separate associated revenue streams and budgeting oversight. Finally, some elements are usually associated with court system functioning but tend not to be regarded as a part of


o to be tied to a county-level funding mechanism for the courthouse facilities, which accommodates the reality of activities being carried out in them but that also contributes to blurring the definitions and boundaries for what is, or is not, a cour


ic descriptive questions arise concerning how particular states deal with fee and fine revenue generated by their court systems. In particular, may the courts to retain (or bank) any of the revenue to cover their own expenses? And what fraction of co


generator the courts really are.” Although interviewees suggested that some Ohio counties might use a portion of the fee revenue to support the operation of their local courthouses, they also observed that there is no consistent, state-level tracking


ation on the collection of fee revenues by the courts. See, for example, Supreme Court of Ohio, 2011.
 18
court system revenue collection in recent years.17 The revenue collected by the California courts is reportedly remitted to a mixture of purpose


ue either.
18 For more detail, see Overholt, 2012. See also Overholt et al., 2006.
19 We were unable to reconcile this statement with an official FY 2011 summary of California court system funding sources, which did not specifically identify a state


n commenting on the shortfall in SCRTF funding, the chief justice of the Florida Supreme Court notably observed that “recurrent cash flow problems hinder court efficiency and can potentially disrupt day-to-day court operation” and that, in consequenc


in a flexible form, as opposed to being purpose-dedicated across several (or many) specific accounts. In particular, we were told in interviews that some state legislatures provide for many more court system funding line items than others do—a state


funds and appropriations, and that information may or may not be aggregated, tracked, and disclosed at the state level. Meanwhile, more-detailed tracking of actual expenditures undertaken within a state court system and of revenues generated by that


nue accounting disclosures on an annual basis, whereas several of the other states do not disclose this kind of accounting information, and Ohio apparently does not even track court- generated fee revenues in a systematic way across the state.
Discus


 basics for how courts are organized within a given state and how money passes into them and is spent by them because of this organization. According to our research, at least five descriptive dimensions emerged as being important:
• the breadth of w


far has focused primarily on court system financing and accounting. However, it is impossible to examine the way in which courts are funded without also tangentially considering how they are organized and managed. Any investigation of the flow of mon


s of state court system financing and accounting differ in important ways (discussed in Chapter Two), the fact that there are differences in governance models used in the state court systems adds another important dimension to understanding the state


ce—the determination of the administrative rules for the day-to-day operations of courts spread throughout the state—concerns a core internal management function. Whereas other bureaucratic entities (such as administrative agencies) are part of the m


 Moreover, the variation makes it difficult to untangle the effects of the financial crisis on judicial systems when the systems manage their financial resources in very different ways.
We begin our discussion of governance with three aspects of a st


budget request.
The Florida state court administrator has a large portfolio. Much of this authority and the system’s reliance on the administrator’s professional staff result from some significant restructurings in the Florida courts over several dec


erves as the governing body for the state court system. The Judicial Council of California establishes strategic and operational goals for the state judiciary (Judicial Council of California, 2006). It has authority to establish administrative proced


ver, is of more limited scope than what exists in other states: The state-funded component of the judicial system in Ohio includes only the state supreme court, the courts of appeals, and the court of claims. The state court system does not include t


 a line item for contracts and leases on buildings and facilities; and the third is for jury and interpreters’ fees. By
32
getting their allocation in one large lump sum free of encumbrances, the Judicial Council and the court administrator can manag


more difficult to fulfill its constitutional duties according to the principles of good public management. Moreover, a judiciary that, like California’s, a legislature tells that it cannot carry over its budget or retain reserves over a specified th


from the statewide politics of funding allocations and statewide financial circumstances. Yet the decentralization of governance in the Ohio courts has arguably created a black-hole effect on their finances: At present, there is no transparency or l


 which the budgets are prepared, the ways in which the money can be managed, and the structures of organizing the court administration, would be of limited use in policy discussions about whether state court systems are appropriately resourced.
Looki


iary through
153 separate line items, with no judicial authority to reallocate. Utah state courts, however, get a lump sum for its state-run component.
Ohio uses a system of
88 independently run and financed county courts below a thin layer of state-


ing, to corresponding accounting practices, to the structures of governance and administration, the states are deploying very different strategies for operating the third branch of government.
The main elements that emerge from our review of a small


(whether in the abstract or in reference to a previous year’s budget) is an important piece of the resourcing story but only part of the disclosure that is needed to clarify what the funding status of the courts really is. It does even less to make


al year?
• How many legislative line items are there in the state X budget pertaining to the state court system?
− Are there other mechanisms for purpose-restricting the funds that the legislature allocates to the court system in your state (e.g., th


financing dimensions of its system in its annual report or on its website. In particular, annual reports are universally silent on the budget- preparation process: how the budget is prepared, how closely the budget request matches the ultimate appro


nges faced by state court systems in the wake of the financial crisis, are there comparative advantages inherent in the different governance models used by different states?
• What impact do budget cuts have on court system processes and outcomes? Or


inistrative staff?
− Indigent defense?
− Retirement personnel costs?
• Are there important “silos” of dedicated court system funding within your state? If so, what are those silos, and how do they work?
• Who controls and administers the expenditure


Is there any one question broadly related to this subject matter that we haven’t asked you about, but that you think we should be asking? If so, what is that?
44
References
Baar, Carl, Separate but Subservient: Court Budgeting in the American States,


s, “An Update on State Budget Cuts,” Washington, D.C.: Center on Budget and Policy Priorities, February 9, 2011. As of April 1, 2014:
http://www.cbpp.org/cms/?fa=view&id=1214
Judicial Branch Governance Study Group, Report to the Florida Supreme Court


ational Center for State Courts.
Ohio Office of Budget and Management, The Jobs Budget: Transforming Ohio for Growth, Book One: The Budget Book, March 15, 2011. As of April 3, 2014: http://media.obm.ohio.gov/OBM/Budget/Documents/operating/fy-12-13/bl


ty 2013, Salt Lake City, 2013. As of April 3, 2014: https://www.utcourts.gov/annualreport/2013-CourtsAnnual.pdf
———, “Court Governance,” last modified January 27, 2014a. As of April 3, 2014: http://www.utcourts.gov/knowcts/adm/
———, “Court Organizati


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in this report was sponsored by the Israel Ministry of Public Security and the Younes and Soraya Nazarian Family Foundation with additional funding from the Rosalinde and Arthur Gilbert Foundation, the Diane and Guilford Glazer Fund, and Mr. Stanley


 of benchmarking the police against other police organizations, performance measurement, and deterrence and crime prevention. This document reports the outcome of the resulting two-year project.
The project was jointly funded by the government of the


. . . . . . . . . Using Volunteers Has Many Potential Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . Countries Use Volunteers in a Variety of Ways . . . . . . . . . . . . . . . . . . . . . . . . . . . . EffectivenessofVolunteersIsU


..................................... 77
Figures
 S.1. Conceptual Model of Effective Policing in 21st-Century Israel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1. Conceptual Model of Effective Policing in 21st-Century Israel. . .


r the last several decades, and the police, their governmental partners, and the public desire that policing services keep pace with these changes. To that end, the Min- istry of Public Security, the Ministry of Finance, and the Israel Police enliste


improving the over- all effectiveness of the Israel Police. Relevant tasks included interviews with key informants, a systematic analysis of media content, and focus groups with diverse communities of Israeli citizens. Findings from these analyses re


 problem-solving, and restructur- ing or realigning the organization to better address the other two components.
• Problem-oriented policing emphasizes new and preventive approaches. A problem-solving method widely used by U.S. police agencies is the


 to implementing proce- dural justice, we group the actions the Israel Police can take into two broad areas:
• Demonstrate fair and just procedures: All citizens are treated according to established procedures, regardless of who they are and regardle


f interactions between police and the public to flag and investigate episodes of unprofes- sional or unwanted behavior. Successful transformation of policing cultures requires changes to training and to the assessment of officer performance. For exam


ct evaluations. These arrangements include independent civilian complaint review boards, as in New York City; the establishment of government offices of independent police oversight, as in Los Angeles; hiring a civilian lawyer to serve as the chief o


uated continually.
Apply a strategic perspective to police personnel require- ments. Police staffing should be in accordance with the goals that Israel expects its police to achieve, the missions they are asked to carry out, and the activities they e


ake steps to administer procedures
in a fair, unbiased, and transparent way
Short-Term Actions
Review and standardize policies and procedures
Change policies and procedures that are biased
Review training and ensure that police standardize their proc


ael to lend his experience in framing this project.
This report benefited considerably from detailed and insight- ful formal reviews by RAND colleague Ryan A. Brown, Badi Hasisi of Hebrew University, and Ronald Weitzer of George Washington University


nal police. Approximately 36,000 volunteers are on the official rolls, although many do no more than the mandatory two half-shifts per month.5 The police have a system of command that corresponds to that of the Israel Defense Forces (IDF), with the c


nd about the Israel Police. It was agreed that bring- ing analysis to several aspects of the policing problem might provide a means by which the police themselves could move to the next level in taking an active and leading role in addressing public


t
• deterrence of violent crime and crime prevention.
Within each of these areas, several specific tasks were selected. The central question for the effort as a whole was: “What must the police do to provide effective policing to 21st-century Israel?


e police judge policing outcomes to be successful according to formal measures of policing, public acceptance and recognition of these outcomes are needed for the police to be deemed effective by the citizenry they serve. Thus, even if the crime rate


r 21st-Century Israel
• ChapterFourprovidesrecommendationsforenhancingtheeffec- tiveness of the Israel Police.
• Chapter Five provides our conclusions.
ChAPTER TwO
Understanding Public Perceptions of the Israel Police
 In this chapter, we examine pub


 cameras for this purpose.
In this chapter, we provide an overview of what we learned about public perceptions from these studies and discuss the implications for the Israel Police.
Key Informant Interviews
Interviews with key informants provide a wi


fy main themes so interview notes were neither formally coded nor subjected to formal analysis.
 12 Effective Policing for 21st-Century Israel
Media Analysis
Media analysis can shed light on how the discussion of an issue is framed, whether a certain


Zman Krayot, Yediot Ha’Negev, Yediot Hadera, Yediot Ha’Mifratz, Kol Ha’Ir
Makor Rishon, Olam Katan
Ha’Mevaser, Misphacha—Chadashot Shel Ha’Tsibur Ha’Haredi, Yated Ne’eman, Ha’Modia, Ha’Machane Ha’Haredi, Ba’Kehila, Ha’Eda
Al-Iam, Al-Akhbar, Al-Arabi,


t of articles. The media analysis identified the major themes underlying the reporting on police-related news and examined their recurrence and variance in different types of papers. The themes identified in the papers echoed those described in the k


but the religious and Haredi papers. All stories referred to incidents in which police were in error (e.g., not showing up at crime scenes, lying, stealing arms). In the Arab papers, police “failures” typically involved Arab citizens or Palestinians


ss was primarily focused on its communities’ issues, paying special attention to police handling of sensitive cases and cooperation with the community. The religious papers covered a broad range of topics, including renewal, change, and improvement o


, some com- mentary in Arab papers acknowledged growing police involvement in combating crime in their sector but criticized the manner of that involvement.
Conclusion
Clearly, the police can have only limited effect on underlying sectarian biases in


a, Jerusalem, and Haifa, which account for 17 percent of the population; (3) villages in both the north and the south. In all, we conducted 28 focus groups, each comprising six to eight interviewees and a trained interviewer who conducted the discuss


ael
Olim main groups was that the treatment people receive from the police is largely determined by the specific officer with whom they interact. Similarly, olim8 and Arab respondents suggested that police behave differently with citizens depending o


entified Desired Changes
Focus groups also identified the types of improvements they would like to see, as shown in Table 2.5. Among the most desired improvements were to see the police be more respectful and more empathetic, to make citizens feel sa


h the research team to filter out clips judged to pose possible legal questions either for the police or for privacy protection. This creates an unknown bias in the final sample of clips. One-half of the resulting sample of clips were from traffic st


ficer as working to resolve the problem in fewer than half of all clips (43 percent), and coders judged that the police were trying to resolve the problem in only 60 percent of the clips. Citizens were judged to be satisfied in just one-third of the


teers as well as trends in handling emergency calls.1
Benchmarking the Israel Police Against U.S. Police Practices
The Ministry of Public Security, the Ministry of Finance, and the Israel Police have sought to identify international benchmarks that a


on size squared4
– percentage of population under age 18
– percentage of male population under age 18 – percentage of population over age 65
• crimerates – homicide – robbery – assault
– burglary – auto theft – theft.
We identified the weighted combi


ectively) are
5 Data on U.S. force characteristics were drawn from the Law Enforcement Management and Administrative Statistics dataset collected by the U.S. Department of Justice (2007). Note that this data set does not provide a breakdown according


formed by less-expensive civilian staff.6
6 Some of the number who would be considered sworn officers in the United States would be shacham in Israel. These would cost considerably less than either civilian employees or professional sworn officers. T


her there are aspects of the U.S. approach that might be appropriately adopted for the Israeli context.
Approaches to Policing in Minority Communities
The research on policing in general, and on the policing of minor- ity communities in particular, h


licing minorities or policing in diverse societies (Stenning, 2003; Ben-Porat and Yuval, 2011):
• diversification of the police force (which involves changing pat- terns of recruitment)
• cultural sensitivity training for police officers
• formal ant


ned either the content or the teaching style in police diversity training (Birzer, 2003; Blakemore et al., 1995).
Much of the support for reforms to address minority policing is anecdotal. There is no research on policies that lead to racial discrimi


ization so that it can better carry out the first two components. Community partnerships can range from collaboration with other government agencies, the media, and service providers to more-effective inclusion of the business community.
Understandin


cing (reactive) duties. This, in effect, produces a specialist commu- nity police. Maguire and Wells (2009) indicates that, while generalized community policing has been widely advocated by policing reformers, U.S. police departments appear to have b


th pre-existing community infrastructures” (p. 789).
Problem-Oriented Policing
In problem-oriented policing, the unit of concern is the defined “prob- lem” that has been identified as being important to the public or in achieving policing missions. P


may displace crime to other loca- tions or times where it is less damaging, or it may deter the crime, lead- ing to less of it overall.
Deterrence
There are three main forms of deterrence: general, focused, and spe- cific. Deterrent policing intersec


heavily upon police volunteers as
8 Specific deterrence efforts often involve collaboration with other parts of the criminal justice system, such as probation and parole. In contrast, police can typically implement focused deterrence by themselves. S


s can be especially valuable in assisting with commu- nity engagement and community policing interventions.
Countries Use Volunteers in a Variety of Ways
The review found that models for how to use volunteers are quite diverse across the eight countr


- gests that some departments, such as in Denmark, England, Wales, Canada, Brandenburg (Germany), and Australia, have relatively high ratios of volunteers in relation to regular police (ranging from 1:1.78 in Denmark’s Police Home Guard to 1:18.40 in


e indis- tinguishable from the uniformed police. As a result, volunteers’ actions may be just as important as those of regular police in shaping public attitudes. In this way, ineffective engagement and response or miscon- duct, such as excessive for


ability for police performance. We also advocate reduc- ing the use of general deterrence and using more focused deterrence. This shift in deterrence posture would need to be based on specific, struc- tured changes within the organization. These stra


ny differ- ent variants of procedural justice in policing and the broader criminal
Recommendations for Enhancing the Effectiveness of the Israel Police 53
Figure 4.1
Conceptual Model of Effective Policing in 21st-Century Israel, with Recommendations


ached the issue of proce- dural justice in different ways. Some have provided structured training and established procedures to maintain standards for police behavior in interacting with citizens. Some have conducted reviews of policies and procedure


 outcome patterns reveal unprofes- sional or unwanted behavior
• Develop a performance monitoring system to evaluate individual police on competence, responsiveness, manners, and fairness
  56 Effective Policing for 21st-Century Israel
nity residents


ides detailed information on the nature and character- istics of face-to-face contacts between police and the public, including the reason for and outcome of the contact.
Recommendation: The Israel Police or an independent research entity should cond


ffective than emphasizing personal ethics or morality” (Klockars et al., 2005, p. 1). This survey has been used extensively by U.S. and non-U.S. police departments widely viewed as in need of reform (Davis et al., 2010).
Recommendation: The Israel Po


to rate the competence and professionalism routinely exhibited by individual officers. Moreover, simply knowing that interactions may be subject to later video review and assessment can have a powerful effect on officer behavior.
Recommendation: The


transparency through use of civilian partners to provide credible oversight of police statements and actions
    Recommendations for Enhancing the Effectiveness of the Israel Police 61
achievements, point to improving trends, or explain how police ar


have found themselves in situations that led the public to become suspicious that the management of police behavior and performance was not sufficiently rigorous or candid to ensure the expected level of service. There is good reason to find similar


orting Staff Are Trained in Interacting with the Public
Ensuring that police officers and supporting personnel interact with the public in a way that supports procedural justice requires setting and maintaining high standards of professionalism and p


acham are held, and the high levels of responsibility they are given. Shacham and volunteers may detract from the professional image and performance standards the Israel Police strives to maintain. Several steps should be taken to make
Recommendation


rvi- sion, performance feedback, and accountability, as well as rewards for model behavior. Regardless of the level of direct supervision, all volun- teers need to be held accountable for their actions. For all volunteers, the Israel Police should co


ed and the need to mobilize in the face of national emergencies. Similarly, we have no basis for judging the appropriate level and role of volunteers in car- rying out the broad range of policing missions in Israel. But the police would be well serve


ning
Recommendation
• Design focused deterrence interventions and reduce reli- ance on procedures that are rooted in general deterrence theories
• Develop a best practices database for focused deterrence methods and procedures in Israel
    Recommend


Table 4.5 shows both immediate and longer-term actions for cre- ating a procedural justice model. The steps are derived directly from our recommendations. Table 4.6 does the same for focused deterrence.
Table 4.5
Steps for Adopting a Procedural Justi


on, but also in terms of the cooperation the police receive in pursuing investigations, the respect officers are accorded as they perform their duties, and the quality of officers and staff who can be recruited to the force.
This report has provided


bstantial change in the culture of the organization and the extent of integration across different divisions and between the field and headquarters leadership.
Figure 5.1 shows how the emphases on procedural justice and a focused deterrence program m


tion, 2009, pp. 133–143.
Ben-Porat, Guy, and Fanny Yuval, “Minorities in Democracy and Policing Policy: From Alienation to Cooperation,” Policing and Society, Vol. 22, No. 2, November 2011.
Birzer Michael L., “The Theory of Andragogy Applied to Polic


 14, No. 1, 2001, pp. 59–74.
Gould, Larry, “Can an Old Dog Be Taught New Tricks? Teaching Cultural Diversity to Police Officers,” Policing: An International Journal of Police Strategies and Management, Vol. 20, No. 2, 1997, pp. 339–356.
Graber, Doris


 “Policing and Community Safety Partnerships,” web page, 2012. As of January 10, 2013: http://www.nipolicingboard.org.uk/index/our-work/policing_and_community_ safety_partnerships.htm
Pelfrey, William V., Jr., “The Inchoate Nature of Community Polici


Vol. 48, No. 6, 2008, pp. 778–797.
Tyler, Tom R., “Enhancing Police Legitimacy,” Annals of the American Academy of Political and Social Science, Vol. 593, No. 1, 2004, pp. 84–99.
Tyler, Tom R., and Cheryl J. Wakslak, “Profiling and Police Legitimacy:


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to other TRIA lines, policy limits and terrorism exclusions are not an option in WC. Insur- ers facing limited risk-management options in WC might be forced to decline WC coverage for all risks to avoid catastrophe exposure, whereas insurers could li


residual markets. Residual market policies are often more expensive than ordinary WC policies. TRIA expiration could thus have adverse impacts on labor incomes and employment even in the absence of another terror attack, though the magnitude of thes


nce of TRIA has again become a pressing policy question.
Workers’ compensation (WC) insurance, which provides medical and indemnity benefits to victims of on-the-job injuries and illnesses, is the largest single P&C line covered by TRIA on the basis


nsable if they are determined to be work- related or to “arise out of the employment,” but the causal con- nection between employment and injury may seem more tenu- ous for terrorism than for more ordinary types of workplace injuries. To better under


irma-
tion of the positional versus increased risk doctrine.10 This view may be prudent, given that the issues at stake have never been litigated in the context of a mass terrorism event. In keeping with the stated perception of our interviewees, we


 whether WC insurers are willing or able to do so is an open question.14
The reluctance of property insurers to cover terrorism in the wake of 9/11 illustrates the influence that catastrophe risk can have on insurers if ample reinsurance is not avail


markets.
Broadly speaking, the first four responses in this list are compatible with insurers continuing to cover nonterrorism risks while either limiting their catastrophe exposure or demanding greater financial rewards for bearing terrorism risk. T


the absence of
this cap. Insofar as exposure to tail risk drives insurer decisions about terrorism coverage, the possibility of NBCR losses may be an important influence on WC market reactions to TRIA expiration.
much greater reinsurance capacity, in


 greatest concern to our interviewees was the tail risk created
by NBCR exposure: Reinsurers are free to choose whether to include NBCR coverage, while primary insurers cannot exclude any occupational hazards from a WC policy. Even reinsurance indust


from looking at rate filing regimes. The effective stringency of rate regulation depends both on the system that is in place and the behavior
of state insurance regulators in implementing that regulation. Rate regulation that explicitly promotes insu


gh changes in insurer underwriting decisions. Absent a dramatic increase in the provision of affordable reinsurance, insurers may tighten underwriting standards against terror risk and decline coverage to high-risk accounts.
Given the deep uncertaint


their own.34 While investment banks and media companies housed in skyscrapers clearly fall into this group, some of our interviewees noted that hospitals, universi- ties, or corporate campuses could raise similar concerns even in suburban or rural s


cymakers to assess market impacts if the hoped-for expan- sion of reinsurance markets fails to materialize. If that indeed turns out to be the case, then it is reasonable to expect insurers to reduce the amount of WC coverage that they write. We now


wide residual market share between 3.5 percent and 11.5 percent since 2000. Residual markets can grow dramatically when there are disruptions in the voluntary market, however. For example, market share of the California State Compensa- tion Insurance


three states perceived to face high terror risk: Illinois, California, and New York. We chose these three states because each exemplifies a different set of residual market mechanisms. Illinois has an assigned-risk pool operated by NCCI, California


e ability to justify post-attack rate increases through changes to more subjective elements of a rate filing, such as underwriting and contingency factors, but there is generally no provision for recoupment of pool losses. Illinois has a use and file


on mechanism that would apply if SCIF exhausted its policyholder surplus.
Although SCIF is publicly chartered, it is legally classified as a public enterprise fund and cannot draw on the credit of the state budget. Resolution of a SCIF insolvency mig


y fund expenses are in use in other states. In some states, guaranty fund assessments may be recouped through rates and premi- ums. The distributional effects of this arrangement are similar to the effects of surcharges, since the costs are borne by


ish between the short- run and long-run incidence of tail risk. Also, for simplicity we do not discuss losses that are covered by private reinsurance or below the TRIA deductible.69 Based on extreme event predic- tions from the RMS terrorism model us


 policyholders in the state that is attacked to the extent that capital depletion for insurers operat- ing in the state leads to higher premiums.
Classification of the risk-bearing structure in the state-fund states is more complicated because it gen


signed-risk states because within- state recoupment will be mediated by the behavior of insur- ance markets. To the extent that insurers replenish capital with statewide rate increases, the tail risk will also be spread broadly throughout the state t


duce their role in financing terrorism losses.
Thus, TRIA expiration could have the effect of redistribut- ing risk such that the burden of catastrophic losses is confined within the state that is attacked to a greater extent, adding to the challenge


related reasons— would be compensable under the doctrines that cover employment- related assaults (Larson and Larson, 2008). This basis for compensa- bility is clearly narrower than positional risk, and the indiscriminate character of many terrorism


spec- tives on Terrorism Risk Insurance in the United States, Santa Monica, Calif.: RAND Corporation, RR-573-CCRMC, 2014, pp. 10–12. As of April 22, 2014: www.rand.org/t/RR573.
14 Natural catastrophes seldom lead to mass casualties in the work- place


 see J. E. Smith, testimony before the U.S. House of Representatives Committee on Financial Services, September 19, 2013. For testimony on model-
ing improvements, see Driscoll, 2013. For testimony on insurance- linked securities, see John Seo, testi


to tiers of terrorism risk yields roughly $1 billion of additional premium per year across all states. (This calculation uses the surcharges to data on covered wages by state reported in National Academy of Social Insurance, 2013.)
30 Dwight M. Jaffe


urance company before investment returns. Even though a combined ratio above 100 percent means that an insurer is spending more on losses and expenses than it collects
in premium, it does not imply that the company is unprofitable after investment re


se in low-risk states during the year between 9/11 and when TRIA was passed in 2002. We found that growth was slightly higher in markets contain- ing cities with high perceived terrorism risk than in markets without high perceived terrorism risk. How


with insurers: Some small WC insurers have expertise in par- ticular industries, which can help limit WC costs through special- ized safety programs and claims management practices. Any benefits from this type of industry specialization are generally


e Report, 2012.
54 SCIF’s TRIA deductible was calculated on the basis of its 2011 direct earned premium (KPMG, State Compensation Insurance Fund: Statutory Basis Financial Statements, 2012).
55 State Compensation Insurance Fund, 2012.
56 The impact o


reports that 29 of the 47 non-monopolistic states (and 7 of the 14 state fund states) have a separate guaranty fund account for WC (personal communication with NCIGF, February 20, 2014).
62 The cost of capital associated with delayed recoupment of th


 revenues.
73 See companion studies for arguments to this effect: Willis and Al- Shahery, 2014; Tom LaTourrette and Noreen Clancy, The Impact on Federal Spending of Allowing the Terrorism Risk Insurance Act to Expire, Santa Monica, Calif: RAND Corpor


hank them for their time. Valuable feedback and comments were provided by RAND colleagues Paul Heaton, Henry Willis, Tom LaTourrette, and Peter Huckfeldt. Frank Neuhauser, execu- tive director of the Center for the Study of Social Insurance at the Un


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documents are protected under copyright law. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of our research


 RAND Center for Health and Safety in the Workplace, see http://www.rand.org/jie/centers/workplace-health-safety.html or contact the director (chsw@rand.org).
 iii
Contents
Preface......................................................................


ital outpatient surgeries to surgeries performed in both hospital outpatient and ASC settings. The Medicare- designated “inpatient only” procedures include high volume WC procedures such as such as multi-level spinal fusions and hip and knee replacem


typically performed in an inpatient setting? What factors does Medicare consider in assessing whether a procedure can be safely performed in an outpatient setting? To answer these questions, we assembled information on the health and safety requireme


e is available regarding patient selection criteria for ambulatory surgery and the outcomes when ambulatory surgery is performed.
To explore potential fee schedule options, we selected certain cervical spinal fusion codes that are Medicare “inpatient


ady considered an ambulatory procedure,1 separately reported codes that are often incidental to a primary code that is already considered an ambulatory procedure, and “inpatient only” procedures that are classified into the same Medicare DRG as proce


nal conditions before an “inpatient only” procedure is performed in an ASC setting:
• The provider has determined that the patient is likely to require less than a 24-hour stay and has assured that the patient’s post-discharge needs will be appropria


 have significantly different ASC facility costs, while the use of instrumentation could add significantly to the cost, depending on surgeon preferences.
Discussion
Current OMFS policies require that the prior authorization process for performing an


e similar to those used in California. Colorado’s fee schedule covers the spinal fusion codes in an ambulatory setting but sets the allowance at the same rate as the ambulatory surgery facility fee for spinal procedures that Medicare already covers i


 of whether an “inpatient only” procedure might be appropriately performed in an ASC setting.
xviii
Acknowledgments
We are appreciative of the support that we received throughout this study from our project officers, Chris Bailey and Irina Nemirovsky


ich are physician owned.
The Division of Workers’ Compensation (DWC) in the Department of Industrial Relations (DIR) is responsible for administration of the WC program. The Division maintains an Official Medical Fee Schedule (OMFS) for medical servi


DRG) to which the patient is assigned. The MS-DRG payment covers the average cost of all services provided by the hospital during an inpatient stay. For surgical procedures, this would include the operating and recovery costs, room and board costs, a


C on physician-owned ASCs, from CMS on Medicare-certified ASCs, and from the accrediting organizations on accredited physician-owned ASCs. We also gathered information on the number of ASCs by licensure, accreditation, and certification status. Final


., a commercial database of healthcare claims contributed by health plans. The WCIS and FAIR Health physician data elements include the setting in which surgical procedures are being performed in California. The services reported as being performed i


 summarizes the policies adopted by a sample of other WC programs. These policies inform what criteria DIR might consider in deciding whether to remove certain procedures from the “inpatient only” list for WC patients.
• Chapter Four reports on our d


r certification requirements
The CDPH regulates non-physician-owned “surgical clinics” by requiring licensure. Section 1204(b)(1) of the Health and Safety code defines a “surgical clinic” as a clinic (or organized health facility) that provides ambul


ient settings have a large degree of autonomy in performing a wide range of procedures, some state laws concerning patient safety do place regulations on their operation. For example, the Donda West Law requires patients to receive an appropriate phy


reditation, and Certification
This section contrasts the standards required for licensure, accreditation, and certification, broken into key survey components, or standards that we believe are particularly relevant when
6 Phone conversation with CDPH


gment. Material risks could include risks with a high degree of likelihood, but a low degree of severity, as well as those with a very low degree of likelihood, but a high degree of severity
• Treatment alternatives, including the attendant material


aturely or are discharged to another care setting requiring clinical supervision; however, ASCs frequently doing this could lose Medicare certification because surveyors review all extended-stay cases to determine whether prior to the surgery it was


, to a hospital, of patients requiring emergency medical care beyond the capabilities of the ASC
• Hospital must be local
• Must have written transfer agreement
with hospital
• All physicians performing surgery in
the ASC have admitting privileges at


cs administered by (1) a • qualified anesthesiologist, OR (2) a physician qualified to administer anesthesia, a CRNA, or an anesthesiologist’s assistant
(410.69(b)), or a supervised trainee in
an approved educational program • Physician supervision o


ber of licensed ASCs, accredited ASCs, Medicare-certified ASCs, as well as an unduplicated count of the total number of ASCs (because the categories are not mutually exclusive). The purpose was to provide context for how many ASCs operate in Californ


rocedures should be provided in an ambulatory setting only if the following conditions are met:
• The provider has determined that the patient is likely to require less than a 24-hour stay and has assured that the patient’s post-discharge needs will


 be expected to pose a significant risk to patient safety. Significant risk procedures are those that generally result in extensive blood loss, require major or prolonged invasion of body cavities, or directly involve major blood vessels.
9 Some phys


surgical procedure can be removed from the “inpatient only” list (Box 3.1). While multiple criteria exist, not all have to be met for a procedure to be removed, and any number of criteria may be used when reviewing the potential removal of a procedu


on- inpatient setting.
Policies on ASC Procedures Adopted by Other WC Programs
We investigated the procedures that selected states use to determine what surgical procedures are covered in an ASC setting (Table 3.1). We used a convenience sample of st


ic policies
Policies for procedures that are not covered by the general coverage policy
None specified.
For other services without a Medicare rate, a negotiated payment amount is to be determined based on reasonable method that identifies a similar e


vely, a particular class of ASCs (e.g., Medicare certified and/or state licensed) are generally equipped to provide the services to the WC population.
2. The procedure is similar to other surgical codes that are currently eligible for a facility fee.


inistrative Data Sources
       Our first objective was to identify high-volume WC procedures that are “inpatient only” but might be potential candidates for being performed in an ambulatory setting. We used Addendum B of the Medicare hospital outpat


the 23 procedures that were performed at least 100 times in the WCIS data. We focus our remaining analyses on this set of procedures. The study procedures account for 83 percent of the “inpatient only” procedures in the WCIS data. Most study procedu


d, cauda equine and/or nerve root
Each additional segment
Total for WCIS High-Volume Procedures
All
CPT Code
Number of Procedures by
Percent of Total Procedures Performed in Ambulatory Settings
Description
      NOTE: High-volume defined as procedure


gery – structural
     22214
 22558
Osteotomy of spine, 1 vertebral segment, lumbar
  Anterior lumbar spine fusion – single interspace
    +22585
Additional spinal fusion interspace
     22600
Neck spine fusion, 1 level, posterior or
  posterolateral


tient settings (1.0 percent).
Table 4.4. Proportion of Ambulatory Surgical Procedures with “Inpatient Only” Status in 2011 OSHPD and FAIR Health Data for Privately Insured Patients Ages 18–64
by Setting
N%
OSHPD 147,383 62 0 1,505,565 4,158


roach with decompression of spinal cord, cauda equine and/or nerve root
+63091 Each additional segment
     0
       32
inpatient hospital, hospital outpatient, and ASC (Table 4.6).11 Only one procedure (CPT 63082) was reported as being done in ambul


s Performed in the Inpatient Setting on WC Patients
To explore the characteristics of “inpatient only” procedures performed in the inpatient setting on WC patients, we analyzed the OSHPD inpatient data for 2011. We focused on the study procedures ide


ft for spinal surgery – structural
22558 – Anterior lumbar spine fusion – single interspace
77.7x Excision of bone for graft
8106 Lumbar and lumbosacral fusion, anterior technique
8136 Refusion of lumbar anterior
MDC 8 MS-DRGs 498– 499 if femur; othe


0
MS-DRGs 515–517
       8199 Joint structure operation NEC
8199 Joint structure operation NEC
8151 Total hip replacement 8514 Total knee Replacement
7789 Partial Ostectomy NEC 7799 Complete Ostectomy NEC
            27487 – Revision of total knee ar


 procedures, the average length of stay was three days or longer and, with
37
the exception of ICD-8133 (Cervical refusions), less than 10 percent of the stays involved either a same day discharge or a one-night stay. For comparison, ICD Code 8102 (O


. While there are also minor differences between those that had autografts and/or interbody cages, the average length of stay is four days, and the percentage of stays that are shorter than two days is relatively low.
Table 4.10. Comparison of Length


volving multi-level fusions, autografts, or instrumentation. When screening search hits for papers of interest, we also reviewed articles that touched on issues discussed and analyzed in this report. These issues include postoperative length of stay


s were identified that examined patient outcomes for hip and knee replacements conducted in either the hospital outpatient setting or freestanding surgical clinic setting. Given the available evidence we can only conclude that at least for some patie


ting for knee replacements remain and require further study:
“Should this [minimally invasive outpatient total knee arthroplasty] be done, and if so, should this only be done only at specialized, high-volume centers or can this be done in a community


stay; readmission rate; causes of readmission
Key Results
Nine of ten discharged day after surgery; one discharged four days after surgery due to bowel obstruction
Implication(s) for Ambulatory Setting, and Key Limitations
Single-night stay may be en


atal complications occur? J Bone Joint Surg Am. 2007;89:27-32.
Intervention / Purpose, Outcomes, and Setting
Please see entry in “Total Hip Replacements” section below
Key Results
Please see entry in “Total Hip Replacements” section below
Implication


em
Reasons for overnight stay: desire to remain hospitalized due to postoperative pain; nausea
Only one patient readmitted in first three months
Implication(s) for Ambulatory Setting, and Key Limitations
Benefit for patients entirely psychological (n


hospital outpatient setting but does not cover autografts, multi-level fusions (other than certain lumbar fusions), or instrumentation used in these procedures. Further, cervical disc arthroplasty is covered, but lumbar disc arthroplasty is consider


 16, and 24 hours after surgery. The nurse also administered 3 doses of intravenous antibiotic therapy in the home.
Key Results
Mean (range) time in hours: ASC 4.98 (1.83– 8.77), operating room 1.49 (0.87–2.20), procedure 0.87 (0.37–1.68), recovery r


al outpatient settingmaybeappropriate;however not all patients appropriate for outpatient setting
Optimal criteria (e.g., age, comorbidities) for determining appropriate setting for patient unknown
Single center, small sample, non- experimental desig


xists for whom inpatient setting is most appropriate option
Patients not randomized to inpatient or outpatient setting (selection bias likely)
            53
    Citation
Trahan et al.
Feasibility of anterior cervical discectomy and fusion as an outp


n ambulatory setting could meet two objectives: 1) reduce WC medical expenditures, and 2) increase worker choice regarding where services are delivered. Ideally, the fee schedule amount should be neutral with respect to where the services are deliver


een where the ambulatory surgery is performed and where it would otherwise be provided on an inpatient basis. Unlike the inpatient rates, the OMFS for ambulatory surgery facility services adjusts only for differences in hospital wage levels across ge


ent rate, the payment should be based on the MS-DRG to which most candidates for ambulatory surgery would otherwise be assigned. In the case of the cervical spinal fusions, 80 percent of the WC discharges were assigned to MS-DRG 473 (Cervical spinal


s that would not be applicable when the services are provided in an ambulatory setting. Analysis of the Medicare data file used to establish the 2014 MS-DRG relative weights indicates that the surgery charges (operating/recovery room, anesthesia, med


 for hospital outpatient surgery.
A study involving 102 single-level anterior cervical discectomy and fusion procedures performed at a single institution investigated the extent to which surgeon choices affected the hardware costs. The study found th


 the allowance:
Option 1: Base the allowance on the Medicare inpatient rate
1a. 85 percent of the Medicare rate (as suggested by SB 863)
1b. 82 percent of the Medicare rate (which is based on short-stay discharges) 1c. 88 percent of the Medicare rate


nce 2004, while the Medicare updates for inflation have been reduced for policy adjustments. The inpatient rate for DRG 473 equals the standard OMFS rate multiplied by the MS-DRG 2014 relative weight ($6,414.72 × 2.2458 = $14,406.18). We used a simil


ed should be minimal. The “inpatient only” allowance should be reserved for surgeries involving spinal hardware.
A number of other issues would need to be addressed if a DRG-based OMFS allowance were established for “inpatient only” procedures. Littl


e outpatient services, the incentives would be neutral with respect to where the services are provided, and payment policies for post-discharge would not be needed. The drawback to this approach is that it is unlikely to provide a reasonable allowanc


ly patients who are likely to require less than a 24-hour stay, assuring appropriate post- discharge arrangements are made, and providing the patient with written disclosure of any financial interests between the ASC and the physician (Table 2.1).
It


rature suggests that two-level cervical fusions and the use of instrumentation for one- or two-level fusions can be performed safely on an outpatient basis. Further, the OSHPD inpatient data indicate that a substantial percentage of patients with cer


ying for “inpatient only” procedures in an ASC setting. Our data analyses and review of the literature do not provide strong support for removing any procedures from the “inpatient only” list with the possible exception of procedures related to anter


he-board pricing methodology. This is because the appropriate allowance might depend on individual circumstances. We considered whether it would be appropriate to remove selected procedures from the “inpatient only” list but not establish an OMFS all


ces might be appropriate for other than device costs, which should not vary by setting.
Our recommendations reflect the principle that the safety of the injured worker is of paramount concern and that any cost efficiencies are secondary. They are gui


cedure that is subject to the multiple procedure discounting rules E= a procedure that is not covered by the Medicare program.
The APC to which covered outpatient procedures are assigned is also shown. The relevant APCs and the estimated 2014 Medicar


ation device C
Cerv artific diskectomy
Lumbar artif diskectomy C
C C C C C C C C
                                                                                T 0050
                        T 0208
                72
         CPT Sta


63285
63286
63287
63290
63295
63300
63301
63302
Description
Remove vert body dcmprn lmbr Remove vertebral body add-on Incise spinal cord tract(s) Drainage of spinal cyst Drainage of spinal cyst
Revise spinal cord ligaments Revise spinal cord ligament


n 22840 - Insert spine fixation device
11 11
8 7
19 18
    22841 - Insert spine fixation device 22842 - Insert spine fixation device 22845 - Insert spine fixation device 22846 - Insert spine fixation device 22849 - Reinsert spinal fixation 22850 - Re


9904.htm#4
California Department of Industrial Relations, Division of Workers’ Compensation, “Official Medical Fee Schedule–Hospital Outpatient Departments and Ambulatory Surgical Centers,” effective April 1, 2013a, b. As of October 24, 2013: http://


“Total hip arthroplasty as a one-night-stay procedure using an ambulatory continuous psoas compartment nerve block: a prospective feasibility study,” Regional Anesthesia and Pain Medicine, March-April 2006, Vol. 31, No. 2, pp. 113–118.
78
Kolisek, Fr


s not associated with increased readmission rates in a national Medicare sample,” Clinical Orthopaedics and Related Research, January 2012, Vol. 470, No. 1, pp. 166–171.
United HealthCare, Total Artificial Disc Replacement for the Spine, Medical Poli


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rily reflect the opinions of its research clients and sponsors.
Support RAND—make a tax-deductible charitable contribution at www.rand.org/giving/contribute.html
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Cover image: Police car equipped with mobile ANPR produced


Program, which addresses all aspects of public safety and the criminal justice system, including violence, policing, corrections, courts and criminal law, substance abuse, occupational safety, and public integrity. Program research is supported by go


. . . . . . . . . . . 64 Police Departments Need to Link LPR Systems to “Effective” Data Sources. . . . . . . . . . . . . . 64
Effective Implementation Frequently Requires Cooperation with Other Agencies . . . . . . . . . . 65 Ensure“Successful”Imple


. . . . . . . . . . . . . . . . . . . . . . . . . . 19 7.1. Notional Large-Scale, Integrated Departmental LPR Setup . . . . . . . . . . . . . . . . . . . . . . 65
Tables
3.1. Statistical Criteria for Selected Departments. . . . . . . . . . . . . . .


have scrutinized their personnel and staffing and have developed system
xi
xii License Plate Readers for Law Enforcement: Opportunities and Obstacles
trainings for patrol officers and investigators. Those that have grappled with the tech- nology’s is


nformation and struggle even now just to share and to store it. Tech- nology to deal with these issues can be daunting; because many departments tapped grants that once were plentiful to buy their systems, they did not plan for repairing, maintaining


s in modern information technology. Recent U.S. Supreme Court decisions on individuals’ locational privacy have conflicted with or left key questions unanswered. Many issues regarding use of this technology remain to be resolved by the courts. In the


AND. We are especially grateful for assistance provided by the profes- sional staff of seven police departments in the United States. We do not name them here due to confidentiality of our sources. We thank our anonymous National Institute of Justice


lerts the offi- cer and, in some cases, always displays a photo so an operator quickly can identify the suspect vehicle.
1 Al Baker, “Camera Scans of Car Plates Are Reshaping Police Inquiries,” New York Times, 11 April 2012.
2 Office of Richard A. Br


gnition Technology (LPR): Impact Evaluation and Community Assessment, Center for Evidence-Based Crime Policy, George Mason Univer- sity, Fairfax, VA, 2010; David J. Roberts and Meghann Casanova, Automated License Plate Recognition (ALPR) Use by Law E


ND believes that these findings overall will add value to the discussion on this technology’s utility. To encourage interviewees’ frank discussion of issues, RAND does not identify departments participating in this report.
The comprehensive nature of


versely, systems that have limited access to data and discard records in a short time period limit the types of uses for which LPR is relevant and do not provide the ability to query past records for ongoing or past investigations. Figure 1.1 illustr


as aimed at criminals on the roads, allowing police to intercept them and terrorist elements. The project was deemed a success, with more than 46,000 arrests resulting from plate recognition.3 As a result of Project Laser, the Home Office invested si


ctivity associated with warrant hotlists. LPR can also be used in a reactive manner for more serious or longer-term criminal activity, such as murder, narcotics, or kidnapping, if a license plate is identified and added to a relevant hotlist. This ca


 parking scofflaws who owed more than $20,000 to the city.16
The technology can also identify persons of interest if the system is linked to rel- evant databases. It can be especially useful in flagging and arresting wanted suspects. A police officer


tments, providing them with a greater knowledge base from which to develop new, data-driven strategies.”22 Ozer continued:
Another aspect of LPR technology is the collection of timely and accurate data about criminals and non-criminals. This feature


lance capabilities or information-sharing with non-equipped vehicles; these cost more. Mobile LPR systems, which do not require extensive infrastructure to support, cost much less than fixed sites for the most part. Fixed sites can cost more because


g asset- forfeiture funds, resources from private insurers, and routine agency budget sources.35 This type of funding may become more common as grants disappear. Given the sys- tems’ benefits, many departments will strive to keep them running through


in the vicinity of a crime scene, as previously mentioned, and their data can help to develop witness lists: Investigators can save time by not needing to spend long periods on time-consuming, door-to-door searches in neighbor- hoods seeking to lear


nts get maximum functionality for cost.
The LPR systems rely on timely data available to them for comparative readings. Databases can provide information on stolen vehicles, traffic offenses, and wanted and missing persons. Although all departments c


st spots like parades, festivals, and driving under the influence (DUI) check-
47 Roberts and Casanova, p. 27.
48 Roberts and Casanova, p. 26.
49 “No License to Steal.”
50 Bruce Taylor, Christopher Koper, and Daniel Woods, “Combating Vehicle Theft in


ups to demand access to official procedures and data and some legislative efforts to ban this technology’s use.
The technology also raises concerns focusing on whether its stored data are “per- sonally identifiable information (PII),” an especially s


 for the Utilization of License Plate Readers, Alexandria, VA, 2009, p. 9.
62 Drivers Privacy Protection Act, 18 U.S.C. sec. 2721 et seq.
63 IACP, p. 10.
64 Ben Eisler, “ACLU Concerned Automatic License Plate Readers May Invade Privacy,” WJLA.com, 30


eventing the information being used for nefarious purposes.
Figure 1.1 in Chapter One illustrates the usefulness of LPR systems based on data retention and access to external databases. This taxonomy can be applied to privacy concerns. As noted above


tion on individuals’ movements and lifestyles, and some privacy advocates and legislators argue that access to these data without probable cause can lead to law-enforcement abuse.77 As one California legis- lator stated recently, “Should a cop who th


it would be protected, the introduced legislation would bar LPR systems until privacy and access issues can be resolved.85
Others fret about private companies putting up plate readers to acquire simi- larly large amounts of data about individuals; ac


ographic and crime-rate statistics to select specific departments. We took care to ensure that each end of the statistical spectrum for each selection criteria was represented, as is described below.
Study Population Categorization Scheme
RAND conduc


uld use their LPR systems.
Border Locations
We also examined how this technology is used on both the northern and southern U.S. borders. These departments operate in unique environments with high international vehicle traffic from Canada and Mexico;


ments in the sample. Instead, we used Census per capita income data for each jurisdiction. Specific budget data for each department would have been ideal to determine the funding support for LPR systems. Lacking such data, per capita income at least


 Ratea
Theft Ratea
Recent Adopter
Northern Border
Southern Border
Per
Sworn Capita Violent Property Vehicle
 201,165
267
26,100
307.5
2,730.7
152.5
A
A
A
B
B
M
N
N
N
A
A
A
A
A
A
N
N
N
M
A
A
B
B
B
Y
N
N
B
B
B
A
A
M
N
N
N
A
A
B
A
A
A
Y
N
N
A
A
B
A
M
A


    28 License Plate Readers for Law Enforcement: Opportunities and Obstacles
LPR use. RAND gathered information on all the study topics and uncovered valuable themes concerning this technology and its uses, as we describe in Chapter Six. These theme


forcement: Opportunities and Obstacles
property crime rate. Its rates of vehicles theft are at median levels. In contrast, Big City is larger, with a population of roughly 300,000, plus more residents in suburban areas outside city limits. Its police


ess several dozen more mobile and fixed cameras from suburban and county police in its area. Big City participates in an integrated, regional law-enforcement cooperative that funds various crime-fighting initiatives, and it has been a principal drive


om an outside agency prevents the increased levels of cooperation evident in larger areas that cooperate regionally. Further analytic study would be useful here to determine whether the RAND observations, made from in-depth information gathered about


e system’s most important targets are suspended registrations and lapsed insurance and parking infractions; a smaller portion of its alerts is for recovery of stolen vehicles.
The interaction of LPR systems is low among North Town, U.S. federal autho


es, but these data are pro- vided to the National Insurance Crime Bureau (NICB) and city authorities can access the information there, meaning that information from in-bound Border Patrol cam- eras is available to them. There does not appear to be an


y, and (3) Cluster County.
DMV-Enabled Cluster County is a county-level jurisdiction with access to data from the DMV. With a population of roughly 1 million, DMV-Enabled Cluster County borders both Cluster City and Cluster County and has a significa


is more effective in sharing information: It can electronically connect its license plate reader system data to several nearby agen- cies but not to the DMV. This real-time passing of information cuts the time needed for officers outside Cluster Coun


ents to standardize their policies. If they resolve their blocks to data sharing, it still is conceivable that the department with the longest retention policy could share personally identifiable information with other departments; this would negate


overnment. Indeed, the checks and balances of the federal structure of our govern- ment were designed to minimize this risk. But the loss of locational privacy via LPR technology could also occur at a local or regional level. A handful of a system’s


seized in violation of the Fourth Amendment should be excluded from admission at trial, an application of the exclusionary rule—a penalty to deter law enforcement from violating the Constitu- tion. Second, in Mapp v. Ohio,6 the Supreme Court held th


at the government did not trespass within the telephone booth was irrelevant. The court held that:
[T]he Government’s activities in electronically listening to and recording the peti- tioner’s words violated the privacy upon which he justifiably reli


ents from one place to another.”15 The defendant argued that “twenty-four hour surveillance of any citizen of this country will be possible, without judicial knowledge or supervision.” The court noted that “if such dragnet type law-enforcement practi


mayor published a concurring opinion in which she argued that “the Katz reasonable-expectation-of-privacy test augmented, but did not displace or dimin- ish, the common-law trespassory test that preceded it.”18
Despite the court’s divergent opinions,


Given the rapid adoption by law enforcement of these systems, as chronicled by this report, it is almost certain that defendants will bring Fourth Amendment litigation challenging the use of this technology. Such litigation likely will reach the Supr


tatute; under- taken on a case-by-case basis in the investigation of a particular violation, misde- meanor, or felony; or other relatively narrow exceptions.23
The state of Maine also has specifically prohibited the general use of “automated license


2013, letter,26 Attorney General Kenneth T. Cuccinelli opined that the Data Act restricted license plate readers’ use by the government. The Opinion Letter first noted that data collected using such systems fell under the Data Act’s defi- nition of


scours the informa- tion collected by multiple plate readers for patterns consistent with criminal activity. Would such use be deemed passive or active? Or suppose that the system is set up to provide alerts about not just to cars tied directly to c


l scru- tiny; the more open-ended and pervasive law-enforcement use of it is, the less likely its use will survive Fourth Amendment scrutiny.
We can identify several dimensions along which law-enforcement use of the tech- nology might vary and which


used defen- dants have considerable interests in vigorously advocating for their privacy rights, they represent a relatively atypical fraction of the U.S. population. Moreover, the fact pat- terns that arise in criminal litigation do not span the gam


́ des auto- routes Paris-Rhin-Rhône (SAPR).
 ChaPtER SIx
Common Themes and Challenges in LPR Use
 An important characteristic of RAND’s research was the analysis of case study data from multiple perspectives. We present our findings as themes that s


so great, whether agencies have access to state motor vehicle department data had a strong influence on their activity with plate reader systems. These data are the source of the vast majority of system alerts, say agencies with access to the informa


tistics on plate reader sys- tems; this requires yet more time and staffing commitment.
Fostering the necessary dedication and enthusiasm by administrative staff required, in turn, commitment and resources from agency leadership. Leadership com- mitm


dominated by two large suppliers and most agencies within a given regional area generally use a single supplier. Some agencies successfully shared data with neighbors. This suggests that technical interoperability may not hamper cooperation, especia


can be problematic, forcing agencies to conduct cost-benefit analyses when acquiring new LPR systems and equipment. In the case of LPR technology for agencies in our sample, they did not need to come up with big sums from their own budgets because m


aders for Law Enforcement: Opportunities and Obstacles
and expand their plate system. With tight budgets the likely norm for a time, spread- ing costs and developing strategies to raise revenues to maintain LPR systems are likely efforts for many dep


he database, and this expedited the passage of information to the field. Several agencies actively were developing means for direct access to their neighbors’ system servers, though this access has been limited until now.
LPR data generally have not


tify investigators, etc.). Several agen- cies encountered challenges in securing sites for fixed plate-reader cameras, co-locating them with existing infrastructure and working with local electric companies or private property owners to power their s


dvantage of the cameras. Therefore, camera cars often were assigned to younger, more technologically enthusiastic officers, who used the equipment more frequently.
Special procedures for using system information as evidence did not appear wide- sprea


or prin- ciples related to privacy per se. For the time being, data storage was often limited more by technical and financial constraints than privacy concerns (see above), although such constraints have been rapidly eroding as data storage becomes m


e if they need to target resources there.
Several departments said the number of jailable offenses derived from traffic stops increases when plate-reader technology is in use. Few agencies have performed quan- titative analysis to prove this, but one


 homes as “111-1111” plates. Most agencies require alert verification via mobile terminals or confirming calls to dispatch before officers act.
Common themes and Challenges in LPR use 59
ChaPtER SEvEn
Agency Lessons Learned
 Here are a number of agen


p period was usually much less than one full-time equivalent (FTE) staffer. There were added demands for staff time for system upgrades or work on underlying operating LPR systems. Agencies considered it to be significantly more work to imple- ment t


uring overtime work to look for vehicles with out- standing traffic warrants. The revenue generated to the municipal court from this type of work could pay for the cost of LPR systems. It is similarly possible that a state can increase its revenue re


ments Need to Link LPR Systems to “Effective” Data Sources
This technology’s utility depends on the quality and integration of the IT infrastruc- ture that enables it, feeds it information, and distributes its results. It can be crucial how well the


jurisdictions to arrange for hotlist updates to be maintained and pushed out. Personnel in one locality interviewed noted that a local police department with exceptional IT talent had worked with the state to create the computer code necessary to pe


-how about its purchase, setup, training, and maintenance, especially in the first year or two of opera- tions. This specialist in some cases was not the system’s sole champion but may have been joined by the police chief, who may have realized the n


g how officers should use and manage LPR data. One agency suggested that officers should not have access to the data without proper training. Another stated that officers seemed to learn more about the technology when a training course used case stud


 to acquire software licenses and facilitate mobile “smart phone” applications.
While cloud-based IT is gaining undeniable momentum in private and public- sector applications, it poses some risks, which most likely vary from vendor to vendor. The sec


onses came from different survey populations, the numbers reflect the keen interest by police forces to tap this technology.
RAND’s research on LPR systems sought to go beyond usage statistics. We framed the technology’s environment in reviews of lit


otential boons.
LPR systems’ utility is dependent on database access and data retention policies and practices. Agencies work with hotlists built with data from multiple sources; the more sources, the more effective the results are. But access to man


alogous to an officer’s keeping an eye out for a specific car or plate associated with a particular crime; the more its use is seen as general surveillance, the more likely courts will find it problematic.
We regard as inevitable, particularly with t