Critical Diagnosis

If you think your HMO is bad, check out what Texas has created for its prison inmates

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.

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