Critical Diagnosis

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

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.

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