Managed care in prisons: Balance care and budgets
Rikers Island latest to join move to cost-cutting
(Editor’s note: This is part one of a two-part series on managed care in prisons. This month, TB Monitor looks at managed care in a New York City correctional facility. Next month, we will focus on how the Texas and New York state prison systems are coping with managed care.)
Rikers Island jail in New York City shifts to a managed health care system this month. In doing so, it joins other correctional systems throughout the nation, an estimated 22% of which have privatized their health care services in arrangements that typically incorporate elements of managed care.
At Rikers Island, health care services had already been outsourced to Montefiore Medical Center. But the switch to a new provider, St. Barnabas Hospital, make clear some belt-tightening is under way.
"Montefiore staff had never had to be cost-sensitive before, and they resisted. From what I understand, that’s why it was bid out," says Lester Wright, MD, MPH, associate commissioner and chief medical officer for New York State Department of Corrections.
Those who favor the trend toward managed care in correctional facilities say it trims bloated health care budgets without sacrificing quality of care; often, they add, health care is improved.
Critics disagree. To trim expenses, they say, managed care environments take aim at big-ticket services including the amount of time clinicians spend with individual patients. But with infectious diseases such as TB and HIV, that kind of economizing means diagnosis, treatment, and patient adherence will suffer, they argue.
New $60 million facility
At Rikers Island, Montefiore’s most significant accomplishment had been to establish a state-of-the-art $60 million, 140-bed communicable disease facility, which sharply reduced the incidence of TB. As to what the transition at Rikers will mean, Eran Bellan, MD, director of the infectious disease service at the jail, declines comment.
"Given the circumstances, it wouldn’t be appropriate for me to talk about this, except to say I’m working closely with the transition group," he tells TB Monitor.
What works so well about correctional managed care is the way it holds providers accountable, not only for costs but for quality control standards as well, advocates say. "If I were an inmate, I’d much rather be in a privatized system," says Doyle Moore, RN, vice president of marketing for EMSA Correctional Care, a Fort Lauderdale-based managed care provider.
Moore describes what ensued when he oversaw a change to managed care at a Massachusetts correctional system. "They saved 24% of their budget, increased staff from 480 to 530, and we got all the buildings accredited within two years."
Sometimes, managed care does a fine job, says Anne De Groot, MD, an infectious disease specialist and associate professor at Brown University Medical School in Providence, RI. But not always.
In an e-mail list server set up for clinicians who work in correctional settings, De Groot says she spotted a post from the physician in charge of TB care at a New York state prison. One of his patients had draining lymph nodes and was found to be infected with a multidrug-resistant organism. Luckily, the physician wrote, the organism was sensitive to streptomycin.
"So he’d prescribed streptomycin and was pleased that this patient was improving," says De Groot. "He was giving monotherapy to a patient with MDR-TB I almost fell out of my chair!" She says she tried to set things straight, but at last word, the inmate had been released and lost to follow-up.
The problem with managed care is simple, De Groot says. "Its focus is to deliver a profit," she says. "In a system where it’s extremely expensive to provide care, you have to cut corners. The way to do that is take away from what’s most expensive the amount of time the physician spends with the patient."
Time is major factor in treatment
The trouble is that treating TB whether outside or inside prison walls is a time-consuming and labor-intensive proposition. "You need a lot of physician/patient interaction so you can establish trust," De Groot says. "If you don’t, the patient has no reason to adhere to therapy."
Cost-cutting also means the caliber of physicians can suffer. "It’s hard to fill those spots. Correctional care is such an underserved area," she says. "So you get lower-level specialists, people who aren’t TB-trained, people who aren’t board certified, and they’re providing care to a population that’s highly TB-intensive."
The result can be an incorrect diagnosis. De Groot notes that one such error led to the outbreak of MDR-TB that struck the New York State prison system in the early part of the decade, when a TB patient was misdiagnosed with pneumonia. It eventually spread to 19 state facilities, claiming the lives of 36 inmates and one correctional officer.
Not all correctional systems physicians have to be highly trained specialists, adds De Groot. "But they need to be trained in TB, so they can recognize it. They have to be committed to providing good TB care," she says.
Though nearly every managed care system has its protocols for TB control, it’s not enough to follow an algorithm, De Groot says. "You do the skin test; you find the PPD-positive people; you put them on INH," she says. "But what if nobody takes the time to see patients? If nobody explains why they need to take their INH? If there’s no follow-up?"
In the best managed-care environments, public health practitioners are actively engaged in the health care system, De Groot says. "They need to be networking, overseeing, and doing quality control," she says. "When that’s in place, things go well; the standard of care gets enforced."
Often, relations between correctional systems and public health providers are strained, says Doug McDonald, PhD, senior research scientist at Abt Associates Inc. in Cambridge, MA. "Public health administrators consider prisons to be part of the public health system," he says. "They want prisons to screen like crazy. But when you find something, you have to treat it."
Plus, correctional systems find it hard to share the perspective of the public health provider. "They already feel their budgets are under attack from taxpayers," says McDonald. "As they see it, why should they spend money so people in public health can reap the benefits?"
Until the mid-1970s, health care in many U.S. correctional systems was abominable, says McDonald. "The health care profession wanted nothing to do with it. You can read about people’s gangrenous feet literally rotting off, stuff like that. It was beyond abysmal."
Then, in 1976, the U.S. Supreme Court ruled (in Estelle v. Gamble) that failing to provide adequate health care to inmates was "cruel and unusual punishment." Overnight, inmates became the only people in America with a constitutional right to health care, says McDonald.
Physicians didn’t race to fill the positions, which tended to be poorly paid, so private industry arose to meet the need, McDonald says.
Inside and outside prison walls, the same forces caused health care costs to balloon, giving rise to current efforts to control those costs. In prisons, the combination of forces tends to be more powerful, experts say.
"Prisoners come from the lower end of the socio-economic scale," says Moore. "They’ve had little access to health care." They’re at greater risk for many infectious diseases, including TB, HIV, and hepatitis, says James E. Riley, executive director of Correctional Managed Health Care, which oversees managed care for the Texas Department of Criminal Justice. In Texas state prisons, for example, the incidence rate of TB is 62 cases per 100,000; outside, it’s 14 cases per 100,000.
You can’t hand an inmate the car keys’
Security concerns add more costs. "You can’t hand a prisoner the car keys, send him off to his appointment, and tell him to be back by noon," says Riley. So every time a prisoner has a medical appointment off-site, two salaried correctional officers must go with him.
Meanwhile, health care consumers everywhere have become more assertive about demanding their rights, says McDonald. "But on the outside, consumers rant and rave about their HMOs." Inside, prisoners sue. "So providers have to act super defensively. The tension is felt much more sharply."
So far, the people who like correctional managed care the most are legislators, says MacDonald. "Managed care means accountability. It means you can write a contract and hold them to it," he says.
That may explain why the art of negotiating a contract with a managed care provider is a hot topic in correctional systems workshops these days.
"Privatization’s not a great thing, and it’s not a terrible thing," says McDonald. "It’s all in the quality of services you provide."
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