Originally published by Houston Press January 22,
If you think your HMO is bad, check out what Texas has created for its prison inmates
Five years ago, as Texas was expanding its prison system into one of the largest in the world, state Comptroller John Sharp was looking for ways to cut costs. For the previous half-decade, the price of inmate health care had been rising at a rate of 6 percent annually. With Texas planning to incarcerate 75,000 more people, a method had to be found to contain soaring medical costs. The one Sharp proposed seemed obvious, for it had already been tested in the free world: managed care.
Since 1980, when Federal Judge William Wayne Justice ruled that the Texas prison system's health care was in violation of the Constitution and had to be changed, the Texas prison system has tried to improve its inmate health care. It's hired more doctors and nurses, contracted with local practitioners near the prison units, stopped the practice of using inmate nurses and stepped up the use of specialist care. Then in 1993, as part of a sweeping audit of the prison system, Sharp urged the Legislature to take one more step and remove the Texas Department of Criminal Justice from health care almost altogether, and instead hand the problem over to two of the state's medical schools. Some 80 percent of the managed care would be provided by the University of Texas Medical Branch at Galveston, which had been giving specialized care to inmates for almost 50 years. UTMB would handle prisoner care in east and south Texas, where the vast majority of the state's prisons are situated, while Texas Tech Health Sciences Center in Lubbock would handle the remaining 20 percent of the units in north and west Texas.
Sharp's proposal was hardly controversial. Sure, plenty of people in the free world hate their HMOs, but what sane Texas politician would want to deny prisoners a taste of managed care, especially if it promised to save money? It must have seemed so just. So in September 1994, UTMB and Texas Tech took over more than 3,000 prison medical workers and a budget of $270 million, pledging to cut costs and improve care for an inmate population that from 1994 to the present has almost doubled in size, from approximately 70,000 inmates to approximately 140,000.
After three years of managed care, the result, according to HMO officials, has been an overwhelming success. So far the state has saved some $125 million as the cost per inmate has dropped from the $182 a month the prison HMO was paid in its first contract to the approximately $160 a month it's paid currently, for a service that includes optometry, dentistry, autopsy and burial. Prison health care managers say the savings would be even higher if current costs were compared to what the cost would have been had the prison system continued to provide its own medical care, and if the price of that care had continued to rise 6 percent a year.
The managers of the prison health care system are not only able to trot out impressive financial statements, they also have a striking array of graphs and charts that show access to care among prisoners has improved while mortality rates have dropped. And all this has happened while the prison system was expanding rapidly, opening a new prison facility almost every two weeks for two years. Inmate medical care in Texas, they say, has become a model for other states.
It's a rosy view, but one that's not universally shared. A state audit released last Friday has raised a number of questions about the prison HMO's basic organization and how it's using the money that it's been allocated. Meanwhile, some inmates and prisoner advocates believe that prisoners had better health care before managed care was instituted, charging that not only has managed care failed to solve some of the prison system's endemic health problems, but that it has actually become part of the problem. The basic principle of an HMO, after all, is to limit care in order to save money, and that can leave prison inmates, who tend to be sicker than the general population because of their poverty and their drug and alcohol abuse, in a particularly vulnerable position. Any number of people can deny them care, from a poorly trained licensed vocational nurse to a physician's assistant at a pill window. Doctors at prison units can override the recommendations of Galveston specialists and take away medications, work restrictions and even crutches, walkers and back braces.
Since UTMB took over inmate care in east and south Texas, prisoner complaints have risen. In fact, state auditors found that while inmate grievances increased substantially after the HMO took over, the health care managers had no means to use grievances "to alert them to potential problems or identify trends, even when the number of grievances exceeds the system average." Among the problems:
*Inmates have been discouraged from getting medication.
*Infectious diseases such as hepatitis, tuberculosis and drug-resistant staph have soared.
*An internal medical audit revealed serious lapses in treatment for HIV and AIDS.
*The Huntsville kidney dialysis unit lost its accreditation.
Granted, Texas taxpayers might feel little sympathy for inmates, but they still might want to know whether they're getting their money's worth. And despite the unquestioned savings, there are some questions about where the funds paid to UTMB actually go. Some $668,000, for example, went right into the pockets of 60 UTMB physicians last year as bonuses, despite the protests of the prison board. Some Texas tax money appears to have been spent helping UTMB bid on providing health services for jails in New York City and for prison systems in other states. And a quarter of a million dollars goes to two highly paid -- and apparently underworked -- administrators who were once employed by the prison system. [See sidebar, page 20.]
And then there is the question of fairness. The punishment for people who commit crimes is the loss of their liberty; lack of medical care is not supposed to be part of the penalty too. But inmates who have not been given a death sentence can nonetheless die in prison from medical incompetence. One former prison health care administrator still shakes his head about a south Texas inmate who died of a strangulated hernia, a relatively simple medical problem to fix. No matter what the inmate did, he said, "no one deserves to die of a strangulated hernia."
In June 1996, inmate Stephen Kadis heard some reassuring news from his physician at the Pack 1 unit near Navasota. Kadis had collapsed twice with chest pain during the previous two months, and had been sent to specialists at UTMB in Galveston for tests. The tests indicated a swelling of the lining of the heart, but, Kadis's unit doctor assured him, the problem wasn't serious. In fact, he could go back to work. Work would even make him healthier, the doctor said, especially the kind of work Kadis was going to be doing for the TDCJ: working on the hoe squad, chopping weeds.
Kadis took the news with a certain amount of relief. He was going to be all right. Then 38 years old, Kadis was not a typical Texas inmate. He was well educated, with a master's degree from Columbia University in New York. After a business failure, he had carried a package for some people that turned out to be cocaine. It was a mistake, and he ended up in jail. His first three years were relatively uneventful. But after he became ill, prison life became hell.
For the next nine months, Kadis tried to work on the hoe squad, a job that has changed little since the 19th century. The men are hauled in wagons to work under the supervision of mounted guards, who are instructed to shoot any inmate who tries to escape. Kadis wasn't much of an escape risk. He felt so weak and off-balance, he says, that he kept falling over, and blacked out several times.
Kadis says he filed grievance after grievance with the prison medical authorities during those nine months, but his unit doctor kept sending him back to work. In June 1997 he was sent back to Galveston, which boasts the most advanced maximum-security hospital in the country, where his neck was x-rayed and he was given an MRI. The diagnosis was myelomalacia, a degeneration of the spinal cord caused by a narrowing of the spinal canal. "The specialist," says Kadis, "really didn't tell me anything, just wrote 'myelomalacia,' and sent me back." He was transferred to Ramsey 1 unit at Rosharon with work restrictions that included no lifting of anything heavier than five pounds and no prolonged standing.
But doctors at individual prison units have the right to judge whether an inmate has recovered from his problem and is fit for work, and the doctor at Ramsey 1, just like the doctor at Pack 1, wanted Kadis back on the hoe squad. But this time Kadis refused to go.
"Every day the guard would come and ask me if I was going to work, and I told them, 'You'll have to punish me'," he says. "So they took away three years of good time I had built up."
Kadis kept getting sicker. Eventually, his mother sent his chart to a private doctor, who was immediately alarmed. Myelomalacia is a degenerative disease that can prove fatal without highly specialized surgery. Kadis's family and his lawyer started sending letters to TDCJ officials protesting his work assignment and pointing out that without surgery he would die. One of the letters reached Lannette Linthicum, TDCJ's assistant medical director.
Linthicum doesn't intervene often, but she has a reputation as a sensible and compassionate physician who says what she thinks. Linthicum visited Kadis, he says, "and said she would make sure I was assigned to something where I wouldn't get hurt, and she saw that I got surgery." Last September, in a 14-hour-long operation, specialists at UTMB replaced three of Kadis's neck vertebrae with bone from his hip. "The surgery was as good as can be done," Kadis says now. "The services are fine when you get them, but so many people get them so late that they're crippled or sick."
The question is whether Kadis was just a victim of an incompetent unit doctor who either didn't know what myelomalacia was or was obsessed with malingering -- or whether the specialists who originally examined him in Galveston were trying to avoid a costly surgery. Kadis himself has a very simple diagnosis: "They were trying to kill me."
And he's convinced he wasn't the only inmate in danger from UTMB medical personnel. Kadis recalls a young inmate in his late twenties at the Pack 1 unit who had a heart condition. "His whole family had bad hearts," Kadis says. "He passed out three times and they still sent him out to the fields. They also send asthmatics to the fields, making them sick from pollen."
Thanks to the intervention of his family, Kadis was granted a "special needs" parole, which is typically given only to seriously ill inmates, and is now living with his mother in California. He reports that he is almost completely crippled. "I can't lift; I can't climb stairs," he says. "They quit abusing me, but not anyone else."
Dr. Jason Calhoun, UTMB's medical director for managed correctional health care, is the man in charge of inmate treatment. Recently, he conceded that he knew there were horror stories about UTMB Managed Correctional Health Care. But because of medical confidentiality laws, he said, he can't respond to them case by case. Still, Calhoun admitted that the care is not yet good enough. "We're only a third of the way there," he said.
To show just how far managed health care has come in Texas's prisons, Calhoun can produce an impressive array of data, much of it prepared for legislative committees. One such committee, chaired by state Senator John Whitmire of Houston, will hold hearings on managed care this winter. In addition, the managed care program will be examined as part of the Sunset review process for the entire TDCJ.
And later this year, managed care will have to pass even more stringent scrutiny. For months, lawyers and medical experts for inmates have been investigating prison medical records to see whether Texas's prison health care will pass constitutional muster in the federal court of Judge William Wayne Justice. For years, the state of Texas has been trying to remove its prison system from Justice's supervision, and to satisfy him, state lawyers will have to defend the managed care system in court.
As proof that inmates are not denied care, Calhoun and other prison managed health care administrators are fond of reciting the number of medical "encounters" the UTMB system has recorded. Encounters are registered by nurses and physicians on bubble sheets, one-page forms that UTMB created to track information. The health care providers fill in a circle on the form with a list of medical problems and treatments, the identify of an inmate and provider and so forth. Bubble sheets are sent daily to the administrative headquarters of UTMB Managed Care in Galveston, placed on a conveyer belt and run through a scanner, producing a wealth of computerized data. Something on the order of 3.6 million encounters were registered last year for 100,000 inmates under UTMB's care, meaning that the average inmate saw a doctor, a nurse or a physician's assistant 36 times in the course of a year. Managed Care officials cite the high numbers of such encounters as proof that inmates are not only getting access to care, but seem to be seeing medical personnel much more frequently than people out in the free world.
Unfortunately, raw numbers don't tell the whole story. In part, the number of medical encounters is high for prisoners because they have no choice but to go to a physician. People in the free world don't have to see a doctor or nurse every time they have a headache or cut their finger or have a cold. Instead, they can go to their medicine cabinet or the local drugstore. Prison inmates go to the infirmary.
The chief administrative officer for UTMB Managed Care, Leon Clements, says that one of the places the prison health system has made significant savings has been in the cost of drugs. In part, that's because drug purchases have been consolidated under a mass purchasing program through the University of Houston College of Pharmacy -- and such consolidation must undoubtedly make a difference, though Clements doesn't offer any data to support that contention.
Still, the real key to cutting drug costs in any medical care operation is to keep people from taking drugs in the first place. Before the prison system had an HMO, individual units were in the habit of providing a basic home medicine cabinet at the picket station at the end of cell rows. An inmate who had a headache or indigestion in the middle of the night could get permission from a guard and get some relief. Inmates with chronic conditions such as diabetes or tuberculosis, which require daily medication for a prolonged period of time, would be given "pill packs" with a 30-day supply of medication that they could keep with them. This was far from a perfect system; it did create problems with trafficking in and hoarding of drugs. Still, according to prison experts, security had some idea of which inmates could be trusted with pills and which couldn't.
With the advent of managed care in 1994, all medication must be taken at pill windows, and no one is allowed what were called "KOP," or Keep On Person, pill packs. In most units, the pill window is open only twice a day, once from 3 to 5 in the morning, and once in the evening, usually from 4 to 6 p.m., which tends to fall during mealtime. There is a water fountain at the pill station where the inmates must take their medicine under the eye of a guard. If 70 to 80 inmates require medication, the wait for a pill can be onerous and long, especially if an inmate is disabled or ill. And if the line is too long and all the patients are not served by closing time, the window is simply shut, and those who didn't get their medication have to come back later. In some cases, inmates have to choose between eating dinner or getting their pills. Chronically ill patients, such as those infected with TB, sometimes simply give up hope and don't bother to take their medication. For many inmates, it's not worth the hassle of going to the infirmary and waiting three days to see a doctor for something like the flu, a cold or a headache. As a result, drug costs drop.
But managed care didn't reduce the cost of inmate health care by millions simply by depriving inmates of aspirin, decongestants and antacids. One of the prison health system's former administrators, Jim Cook, says costs have also been cut by eliminating personnel that he says are necessary to provide adequate care. Cook is a former naval officer who spent his military career in health administration. After retirement, he worked in health care at Sam Houston State University at Huntsville before being recruited by the prison system ten years ago.
A large-bellied, chain-smoking, no-nonsense man, he hardly seems the type to get sentimental about medical care for criminals. But Cook is also a man who goes by the book. "I don't play games," he says, "and I'm not a politician." To Cook's way of thinking, if it isn't documented, it didn't happen, and Cook has seen plenty of documents over the last three years that make him believe UTMB has been making money for itself and some of its administrators and physicians by withholding care.
Cook began at TDCJ as a unit medical administrator in August 1987 and two years later was given a regional administrator's job overseeing ten units. After the TDCJ building boom started in 1989, he at one time supervised the medical care at 20 units.
"When UTMB took over," he says, "no one had any experience at a prison unit. The approach was typical of managed care: Cut costs, cut care."
Cook checked on the quality of care by going directly to the unit records. "I would go in and say 'let me see the sick-call log for last Thursday,' and then I would pull all the records," he says. "I would look at when the nurse saw the inmate, did she take signs, what was the disposition of the case.
"I found it much harder to track after the HMO came in. They put such a fear into people that they wouldn't report the true facts. The outcome was predetermined. They were going to make the record say what they wanted it to say."
Part of the HMO's problem, Cook says, is that UTMB has eliminated important clerical positions and consolidated nursing positions with administrative positions. The result is both inadequate care and inadequate documentation.
"I had an inmate shipped from the Hodge Unit in Rusk, which houses mentally retarded inmates," Cook says. "He was a brittle diabetic and had bad teeth, and we sent him to Galveston to have his teeth extracted. UTMB put him on a chain bus to Estelle Unit for a layover before returning him to Hodge. No one read the orders on him. He didn't get insulin for six days, and he died. He should have been kept in Galveston, and if he were moved, moved by ambulance. Several orders written by the dentist were ignored."
Transportation is one of the problems that besets UTMB's managed care program for inmates. When inmates are transported to Galveston, it can be expensive. Cook says he proposed that the system buy motor coaches and equip them as specialty clinics, then contract with a local specialist and have that physician see the inmates on site, rather than spend three or four days hauling them across the state.
The approach is one he saw in the Navy, Cook says, and it worked well. But he got nowhere when he raised the suggestion with the prison system, perhaps in part because it had the disadvantage of cutting outsiders in on UTMB's exclusive deal.
Still, there is much to be said for what UTMB has accomplished. It has built an HMO during an extremely expansive time of growth in the prison system. It has also created an innovative telemedicine system that some inmates like because they can be examined by a UTMB specialist via telephone and television without the inconvenience of traveling to Galveston. At the same time, UTMB's managed care system improved physicians' salaries and gradually slowed turnover, though the actual number of doctors and registered nurses has stayed relatively steady, despite the boom in the inmate population. What has been increased is the number of dentists and licensed vocational nurses, who are less expensive than RNs.
Seeing a UTMB physician, even if by remote control, can beat the hell out of seeing some of UTMB's unit physicians, at least eight of whom have had restrictions placed on their licenses for problems ranging from sexually molesting patients to botched abortions to drug and alcohol abuse.
But if a restricted choice of doctors is an element the prison HMO shares with many of its free world counterparts, there is something the inmate managed care program has been missing since its inception: co-payments. As of January 1, though, that changed. Although 85 percent of the prison population is indigent, in the last session the state Legislature passed a bill requiring a $3 co-payment for all inmate medical visits. Prison officials assert that no inmate will be denied care if he can't afford the co-payment, and also say chronically ill patients won't have to pay over and over again. But prisoner advocates are still concerned; as they point out, there are plenty of safeguards in prison regulations that in theory ought to work and don't.
And co-payments rankle for another reason. Although inmates sometimes work themselves sick in the TDCJ's factories and fields, in Texas, unlike many other states, they're never paid even a token wage. So they can't earn money to pay for their medical care, having instead to depend on savings, or funds sent to them by friends or family members.
The best result from co-payments would be to cut down on malingering, in which prisoners claim to be ill simply to avoid work (a problem that's been around prisons long before managed care came in). The downside, of course, is that some inmate with only $15 in his commissary account might hesitate to visit the infirmary for what seems to be a small problem, and thus let a simple medical condition become a serious one.
Too, it could reduce the impressive numbers of "encounters" UTMB officials toss out to show that managed care is working. Of course, measuring health care by the number of inmate medical encounters may work as a public relations tool, but it's actually irrelevant to the standards of care that the prisons must meet, standards set both by the federal courts and the National Commission on Correctional Health Care, the HMO's outside accrediting agency. These standards require that once an inmate files a sick-call request, he must be seen by a nurse or a physician's assistant within two days and, if the problem warrants, by a physician within seven days. The paperwork that determines whether a prison unit is meeting these guidelines has nothing to do with encounter forms.
Instead, access to care must be measured by how well the unit tracks and disposes of individual cases. Adequate medical care is measured first by whether the inmate is seen in time, and second by the appropriateness of the treatment. Providing proper care requires keeping accurate medical records, and while encounter forms are good for public relations, they mean little to medical records specialists. What, for example, does it mean if a nurse checks off a bubble that says an inmate was seen for say, diabetes, if he wasn't properly evaluated?
As it happens, there is no bubble on the HMO's encounter form that says "malingering," but according to nurses, former inmates and prisoner advocates, many inmates are sent away with just that evaluation.
And some inmates do malinger, admits a former nurse who worked in several prison units for more than ten years. "But from the beginning you are taught to treat them mean," she adds. "There was never anything wrong with an inmate. Anybody that treats them nice is called an inmate lover."
"A nurse is supposed to look at an inmate," she says, "but sometimes they'll turn down a request if they judge the inmate has already been seen. They'll write a 'no-show' on appointments because the inmate can't get out for security reasons. A guard might fail to get them out for various reasons, or there might be a lockdown. A lot of focus is on getting rid of the sick-call requests."
The only way to legitimately determine both the quality of care and the adequacy of access is through sampling medical records, and the prison system has an office dedicated to that purpose, the TDCJ Health Service Division. Its team of auditors is supposed to review units annually and make recommendations for corrective action. Last May, the Health Service Division summarized the five most frequently found problems in the units it had audited. Of 58 units audited, 41 failed to follow up on a program of flu immunizations for offenders at special risk; 42 failed to adequately account for emergency room procedures; 44 could not properly document that they had counseled inmates in need of therapeutic diets; and 49 could not document that they had offered vaccines to inmates at risk for pneumonia, which would include the elderly, the chronically ill and those with HIV.
But the most revealing statistic was that 48 of the 58 units missed an audit question concerning their documentation for access to care. In short, units were saying they had provided care -- but didn't have the paperwork to prove it.
Curiously enough, such problems haven't hurt the accreditation rating of units. The National Commission on Correctional Health Care has never turned down a Texas prison unit for accreditation. And on the state level, units that are not in compliance have frequently been given extensions to get into compliance by Dr. Michael Warren, who until recently was the medical director of the TDCJ Health Services Division on a part-time basis.
Compliance was also a problem pointed to in the state audit released last week. Although all units are supposed to be fully accredited by the NCCHC, auditors found that once deficiencies are found, "no on-site follow-up visits to the units are conducted to verify the corrective actions actually took place" and furthermore, "no criteria or performance standards exist to determine, quantitatively, when a unit is assessed to be in compliance."
Despite the often critical stance of TDCJ's medical auditors, Warren rarely criticized UTMB's managed care -- in part perhaps because he was spending most of his time employed by UTMB as its chief of urology. When the Press asked TDCJ director Wayne Scott how Warren could manage such an obvious conflict of interest, Scott replied that "Dr. Warren is here at our request, not at anybody else's, as part-time medical director. Mike Warren is a guy, we believe, that can separate those two responsibilities."
Scott added that he had been seeking a full-time medical director for the past couple of years, but hadn't found a candidate he liked. But two days after talking to the Press about Warren, Scott fired the doctor, and sent a secretary to Galveston to collect his state computer and car.
Critics say that the Health Services Division is understaffed for the volume of work it's charged with handling, but last fall, help seemed to be on the way when the prison system began trying to fill 38 new positions. But nobody ended up being hired because, Scott says, TDCJ decided to think about having the audit work done by a private contractor rather than by state employees.
In general, criticisms of UTMB's inmate medical care have been met with resistance and denial by UTMB officials. Alarmed by deaths at its Stiles Unit in Beaumont, where UTMB has moved convicts seriously ill from HIV and AIDS, in September 1996 the TDCJ board ordered its Health Services Division to conduct a "mortality review" of 24 inmate deaths. A task force of physicians and nurses who reviewed the unit's medical records found that 16 of the 24 cases had been handled improperly. Although the Stiles unit was supposed to specialize in dealing with AIDS, here are some of the findings concerning these deaths:
*"Poor recognition by ... staff of signs/ symptoms of acute infection."
*"Incorrect diagnosis of HIV made by Stiles physician."
*"Patient was left in his cell in general population despite recurrent fever, cough, disorientation and inability to walk to clinic."
*"Patient was housed inappropriately ... and was gassed in the infirmary."
But protease inhibitors are expensive as well as effective. And the high price of such drugs, says Leon Clements, the chief administrative officer of UTMB's correctional managed care program, may limit any further reductions in the cost of prisoner care.
When UTMB took over the managed care of Texas prisons, it had a lot of work to do. Some of the system's existing medical staff was incompetent, and had to be retrained. Turnover was high, something that has been reduced. Not that there aren't still plenty of job openings available. Take, for instance, the job description of licensed vocational nurse for the prison system. In December, Managed Care posted 28 openings for LVNs, who are the first line of defense in medical matters. An LVN, the job description says, is responsible for "respond[ing] rapidly to emergencies at any location on the unit, and if indicated perform[ing] CPR."
Unfortunately, rapid response wasn't the case at 5 a.m. Saturday, November 22, 1997, when a 48-year-old inmate named Virgil Kimble fell off a toilet in the H pod at the LeBlanc Unit in Beaumont. Kimble was knocked unconscious and soiled himself. Inmates called a guard, who called the unit's infirmary, and 15 or 20 minutes later, two LVNs came in, cleaned up Kimble and started talking to him.
According to a statement signed by seven inmates at the scene, the nurses seemed to be "goading and bullying" Kimble, who was gasping for breath. He finally managed to walk off the wing to the infirmary, about 400 yards away. (Because of a faulty design of the dormitory doors at the LeBlanc unit, neither a wheelchair nor a gurney can pass through them.) A half-hour later, Kimble walked back to his dormitory and said he thought he was all right.
At 4 o'clock that afternoon, he lay down on his bunk and died. Several inmates beat on the glass door and the guard immediately called the medical staff, but the afternoon shift, consisting of a male and female nurse, took an hour to get there. By the time they did, Kimble was cold.
According to one inmate, "they did two or three blows on the chest" and called for a stretcher. "Then they put an oxygen mask on him, but if a guy's not breathing, oxygen won't do him any good."
Kimble, who was serving a 12-year sentence for burglary and drug possession, seemed to have no family and few friends aside from some pen pals in other prison units. The final service he received from his HMO was not a trip to the emergency room, but an autopsy and (if no family claimed the body) a burial. The state economizes on the burial, too. Each grave at the cemetery at Huntsville is marked with a white cross, but the state wastes no money putting a name or even a number on them.
It's hard to say that Kimble died because his medical care was provided by an HMO; it's possible he might have died in a non-HMO arrangement as well. But the circumstances of Kimble's death contrast sharply with what every top prison health care administrator told the Press. Every unit's nursing staff, they said, is especially attuned to responding to emergencies.
Of course, the final question might be, so what? So what if prisoners are poorly cared for? So what if they get boils and rashes from infectious staph, or their TB goes untreated because they've lost hope and won't get up at three in the morning to wait in line at a pill window? So what if prison is unpleasant?
The problem with that line of thought is that, like it or not, most inmates don't stay in prison forever. Eventually, they're released, filled with resentment and cynicism at what the free world calls justice.
And whatever money the public has saved on health care behind bars, it could end up spending again when inmates show up at the doors of tax-funded clinics and hospitals.