The Fix Is In

UTMB is under fire in Dallas for its jail health care. So why is Houston ready to install it here?

"He has been forced to take medication he was allergic to and at one time went into cardiac arrest because of that and had to be airlifted to Hermann Hospital," Dill says. "Last week, he tried six times to go see the nurse to have his nitroglycerin refilled. If he doesn't have it, it can kill him."

While her husband's care has improved, Dill says it is only because of her involvement. As chair of a prisoners' rights group called Texas Citizens United for Rehabilitation of Errants, Dill regularly receives letters recounting horror stories from inmates about the state of health care in state prisons.

She says the Dallas County story is the rule -- not the exception.

"It's the biggest farce you can imagine," Dill says. "I mean, they're getting three hundred-plus million dollars a year for health care that isn't provided."

It can be difficult to get an objective view of UTMB's performance. The Texas Department of Criminal Justice itself has limited oversight of the health care network inside its facilities. The schools are charged with the self-serving task of reporting on themselves, Dill says.

To counter the bad press the group has been receiving in recent years, UTMB paid the nonprofit Texas Medical Foundation for a six-month review of operations. What turned out to be a glowing review was compromised not only by the funding source, but by TDCJ's decision not to allow researchers to talk with inmates or observe jail practices because of "security concerns." It is for that same reason that city jails have a long-standing policy of not allowing tours by members of the media, a police spokesperson says, rejecting a request by the Houston Press to observe health screenings of inmates by health department employees. Such tours, however, have been allowed through the years for politicians, "visiting dignitaries" or lawyers investigating various potential abuses, according to another jail official.

It took media affairs representatives more than a week to return word from the police captain in charge of jail operations that "the city won't be giving tours of the jail anytime soon."

Access is another reason Puisis's report is so important. Even though UTMB keeps much of its operations secret, Puisis was granted access to Dallas County inmates as well as to jail and medical staff. The stories they told him reflect an overworked medical staff operating on a "survival mentality" in which staffers scramble from one emergency to the next without ever developing the ability to operate an actual health program, Puisis wrote.

Understanding just how the UTMB facilities are staffed is difficult, since the group has declared its budget "proprietary." But it is clear that UTMB's "cluster system," adopted in a partial response to budget reductions imposed by the state legislature, requires staff members to work in different positions for various prison networks. The Dallas County jail director, for example, is charged with overseeing 17,000 inmates at nine different facilities even though his position is funded by Dallas County.

And though UTMB has discussed increasing medical staff in Dallas County, Puisis says that the "general practice" of the group is to reduce staff -- something UTMB officials deny.

But perhaps most disturbing for the future of Houston's jails is the very thing that makes UTMB desirable to city leaders: its use of electronic record keeping and telemedicine.

Puisis found that technology in Dallas County jails had become a replacement for direct physician involvement.

"For most patients, their care involves physicians or nurses reviewing an electronic version of a scanned intake form written by a nurse who is seeing patients in a setting without privacy and not having performed a physical assessment," Puisis wrote.

Further, the reliance on telemedicine means that only one in four inmates with a chronic illness is ever physically seen by UTMB physicians. Instead, doctors are inundated with as many as 100 electronic records they must review each day. Medications are dispensed 12 months at a time without doctors ever seeing their patients. And nurses routinely underestimate the severity of diseases in their reports, enabling doctors to ignore what they believe are not serious cases.

The report suggests this is likely because of a lack of clinical staff.

Such shortcomings may have contributed to some questionable deaths at the Dallas County jail.

Puisis found that a suspiciously high number of these deaths were listed as "cardiac events." In the one case he reviewed, Puisis found the inmate more likely died from electrolyte abnormalities from liver disease complications -- something jail staffers knew about but failed to "treat in a timely manner."

Owen Murray, chief physician executive for UTMB, insists that "all those people are being taken care of by those nurses and triaged appropriately" and adds that, in any event, "talking about any patient's medical record is not something we can do."

Minus one spike in 1998, when 17 deaths were logged, inmate deaths in Dallas County since 1995 averaged seven per year until UTMB took over in the fall of 2002. While not all 15 deaths that year took place under its watch, UTMB was in total control the next two years, when there were 13 and 12 deaths.

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