Teaching centers take larger role in prison care
University model’ brings more expertise, some say
(This is the second article in a two-part series on the impact managed care is having on Tuberculosis treatment in prisons.)
For many of the nation’s overburdened correctional systems, increasing inmate populations and soaring health care costs have combined to make managed care look like a logical solution, if not an irresistible one.
As a result, the number of prisoners whose medical needs are now tended to by private firms is growing by 20% per year. In 34 states, prison systems already have privatized medical care to some extent; of the 34, 19 states have switched to totally privatized systems, says Gary McWilliams, vice president of sales and marketing for the nation’s biggest private vendor, Correctional Medical Services (CMS) in St. Louis.
But critics say the trend is a dangerous one. In Pinellas County, FL, for example, the inmate of a jail serviced by EMSA, a Ft. Lauderdale-based vendor, apparently suffered a heart attack and died before she was finally taken to an emergency room 13 hours later. In Norfolk, VA, an inmate under the care of CMS also died after a medical assistant forgot to schedule his dialysis.1
Managed care’s emphasis on cost-containment is especially cause for concern when it comes to treating tuberculosis and other infectious diseases, some add. Private vendors often hire low-caliber physicians who either fail to spot TB or else treat it improperly, says Anne De Groot, MD, an infectious disease specialist and associate professor at Brown University Medical School in Providence, RI. Also, cost-cutting principles espoused by managed-care providers may not allow enough time and hands-on effort to make sure prisoners complete TB therapy, De Groot says.
Partly to keep money from flowing out of state coffers and into private hands, and partly to avoid the excesses of private vendors too narrowly focused on the bottom line, some states are moving to another alternative known as "the university model."
By handing over medical care of prisoners to state university medical schools, the new model tries to wrap some of the expertise of a traditional fee-for-service system around the cost-cutting measures that form the core of managed care, proponents say.
Georgia, Texas, and Connecticut have moved to the university model, and Mississippi is actively exploring a switch. At least a dozen other correctional systems are said to be interested in moving to the new system.
In Texas, moving medical care from the oversight of the Texas Department of Criminal Justice (TDCJ) to that of two state university medical schools has proven to be "a win-win situation," says James Riley, executive director of Correctional Managed Healthcare, an oversight body created by the TDCJ.
Prison administrators, burdened by health care costs rising at 6% per year and with an inmate population that’s tripled since 1993, were happy to turn over medical care to providers experienced in serving indigent populations, Riley says.
At the University of Texas Medical Branch (UTMB) in Galveston, and Texas Tech University in Lubbock, school administrators liked the new arrangement because it provided a source of revenue they could use to plug holes punched in their budgets by recent cutbacks.
Taxpayers, too, are happy, with per-inmate health care costs down from $5.25 a day, to about $5 a day, Riley says.
CMS’ McWilliams warns that states are going to find the university model is more expensive. By comparison to Texas’ $5 a day figure, he says, CMS has whittled health care costs to $4 a day in Missouri and to only $3.25 a day in Alabama.
Costs also are hidden by the fact that states tend to move money out of one pot when another runs dry, McWilliams says.
He adds, "There’s a tendency with university models to order a lot more tests and do other unnecessary things that drive up costs."
Saving money isn’t the only point’
But saving money isn’t the only point, says Brett Rayford, Psy.D, director of health, mental health, and addiction services for the Connecticut Department of Corrections. "Many of the private vendors have gone in and saved money, but the level of care they’ve provided has been less than desirable," he says. "That penny-wise, pound-foolish approach can really come home to roost."
Plus, Rayford says he prefers dealing with a fellow state agency to wrangling with a private vendor from out of state. "The atmosphere is much less adversarial and much more collegial," he says.
A misconception about the university model is that universities supply the staff, prison administrators note. In Georgia, for example, the Medical College of Georgia in Augusta doesn’t actually provide doctors and nurses; it just employs them, says William Kissel, director of health services for the state’s department of corrections (DOC). As part of a consortium of universities, the school can leverage good deals on formulary and supplies, and it provides a lab service, Kissel says.
Someday, the school may also begin to rotate residents into the prison, a prospect Kissel relishes. "That way, hopefully we can grab some qualified people who find they enjoy practicing medicine inside a correctional system," he says.
In New York State, a hybrid approach
In New York State, once beleaguered by an outbreak of multidrug-resistant TB that made headlines around the country, the DOC has opted for a piecemeal approach that allows for more picking and choosing.
"What we can do in-house, we keep in-house," says Lester Wright, MD, MPH, associate commissioner and chief medical officer for New York State Department of Corrections. Thus, primary care is done on-site, while the system turns to outside sources in managed-care arrangements that feature risk-sharing and capitation for most specialty care and acute hospitalization, Wright says.
The exception is TB control, he adds. "We defined that as our business, not that of the contractor," he says. "The reason is that TB has been such a critical issue in this system for the past six to eight years, we don’t dare let go of it." Thus, the New York corrections department employs the 18 nurses who handle TB screening and provide directly observed therapy, and maintains the 300-plus respiratory isolation rooms spread out across the system.
Another way correctional systems are trying to trim costs is by exploring high-tech ways to provide primary or specialized care. "You can’t exactly hand a prisoner the car keys, send him off to his clinic appointment, and tell him to be back by noon," says Riley. Electronic solutions and telemedicine obviate some of the need for transportation and security that run up medical costs every time a prisoner goes off-site.
New York has begun using teleradiology to read X-rays at three sites, for example. The system works "remarkably" well, says Wright, who plans to expand the technology to other sites.
At Texas Tech and UTMB, specialists use video conferencing, at a cost of $104 per session $32 less than the cost of taking a prisoner to the hospital.
Telemedicine another way to hold down costs
How far telemedicine can extend its reach is still up for debate. "With the proper handpiece, you can get a 25-inch picture of someone’s eardrum or down their throat," says Riley. "You can put on a stethoscope, and at the other end, a specialist can listen in digitized stereophonic sound. You can do everything but touch the patient."
In Connecticut, Rayford is more cautious. "If you get the equipment with all the peripherals, you can go further than primary care, but they’re still working the bugs out," he says.
Georgia’s Kissel agrees. "We don’t feel telemedicine is saving us money yet, but we think eventually it will, especially in primary care," he says. In the arena of specialty care, Georgia hasn’t generated enough volume to justify the cost of telemedicine, he adds.
Telemedicine can be easier on prisoners, says Riley. "For someone who’s truly sick, it’s a lot more humane than shackling the prisoner, making him sit in a vehicle for three or four hours, then making him wait in a doctor’s waiting room for another hour," he says.
One problem that privatization often brings is staff resentment. "Unions tend to go ballistic," says Doug McDonald, PhD, senior research scientist at Abt Associates Inc. in Cambridge, MA. "They feel very threatened by the change."
Union pressure has kept a law on the books in California preventing privatization in correctional systems. Indeed, private vendors have been known to sweep into a system, fire the health care staff, and hire them back at two-thirds the pay, says Rayford.
In Georgia, the department of corrections had hired and fired two private vendors by the time it signed a contract for care with the Medical College of Georgia in Augusta, says Kissel. Prison staff were relieved when the state shifted to the university model, he says. "They see this as a more stable arrangement."
It also pays to spend time easing tensions when a transition is under way, Riley says. Especially important is spending time working on communication between private contractors and correctional officers, Riley says, so that roles are carefully defined and responsibilities are sorted out.
"In Texas, we were working with three separate organizational entities," says Riley. "What we found was that in a correctional setting, you can’t do anything in isolation. There has to be a close relationship between the practitioner and the correctional officer. So you’ve got to have clear policies and procedures."
For the first eight to 10 months of the transition, the staff from all three organizations combed through every function involving health care and security, Riley says. "That included figuring out how each task was done before the transition and how it would be done afterward. Once that was accomplished, more time had to be spent figuring out how to allocate resources."
At first, correctional officers didn’t think the new system would work, he says. "Now they’ve seen the positives, and they’ve begun to accept the change," he adds.
Reference
1. New York Times, Thursday, Dec. 26, 1996, p. A9.
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