Critical Diagnosis

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.
*Doctors at local units have ignored what specialists said about inmates' conditions.

*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.
*At least eight prison unit physicians have had their licenses restricted by state medical boards.

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