Critical Diagnosis

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

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."

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