Sunday, August 21, 2011

Universities won't flock to participate in money-losing prison healthcare

There's a strange and extraordinarily unrealistic proposal being floated on prison healthcare, reports Mike Ward at the Austin Statesman: "Facing a $130 million cut in funding and no fewer patients, officials who operate the network of medical care for state prisoners say they are considering a plan to expand providers to include five additional public medical schools to help those at the University of Texas Medical Branch and Texas Tech University."

Given that Tech and especially UTMB claimed to have been losing money hand over fist BEFORE recent cuts to prisoner healthcare, I have a hard time imagining other universities seeking to get in on the deal without the Legislature forcing them to participate (which couldn't happen before 2013). Hell, UTMB would desperately like to get out of the deal, but the Legislature won't let them.

Another line from the story struck me as at best wishful thinking: "When the Legislature approved funding for prison health care in May, leaders said they were confident the amounts would be enough to cover all the costs — if prison and medical officials worked to make the system more efficient." That's not really accurate. Nobody was confident the new budget would cover all costs, they just hacked away at the budget with a machete without any formal assessment of whether or not constitutional levels of care could still be delivered under the new budget.

Indeed, they'd been told previously that at the old levels of funding prison healthcare was barely constitutional. When the cuts were finalized in May, Grits wrote that "As far back as 2005, UTMB officials said the system was near the brink of failing to provide constitutional levels of care: 'We can't go any farther,' said [Dr. Ben] Raimer, a physician and former chairman of the state's Correctional Managed Health Care Committee. 'I'm certainly not going to be involved with a system that is not constitutional. . . . We're at that line now. One step across it and we're there.' Unfortunately, the state since then has taken several more steps across that line, culminating in this year's outright draconian cuts."

The latest budget cuts coincide with another important change in how prison healthcare is structured, with TDCJ bureaucrats calling the shots now instead of the old Correctional Managed Health Care Committee. Wrote Ward:
The difficulties facing the prison health care system are even more pronounced because the Legislature changed the management structure this year, according to several officials familiar with the discussions but who asked not to be quoted by name because they are not authorized to speak publicly.

Previously, the health care system was coordinated by the Correctional Managed Health Care Committee, created in 1993 to oversee care by UTMB and Tech. The idea was to have a committee with a majority of doctors who could focus on access to care and the quality of care, not prison officials or prison board members, who were not medical professionals.

Now, the Legislature has returned the management to the Texas Department of Criminal Justice, and prison officials are in charge. The committee is shrinking from nine to five members, and the prison board will sign and manage the contracts for care, instead of the committee.

On Friday, the prison board took the first step to take charge, approving a six-month extension of the contracts with UTMB and Texas Tech to allow for new contracts to be negotiated. UTMB and Texas Tech officials were not available for comment.

In the past year, both universities have downsized the hours and staffing at prison clinics to try to stay within the budget. But with drug costs and other expenses rising, they have been hard-pressed to keep up — triggering increasing complaints about slow access to care at many prisons.
Changing the management structure will do nothing to reduce costs and anyone claiming they were "confident" budgeted amounts will cover prison healthcare expenses is either a fool or a liar. Given inflation in the healthcare field and reported losses by UTMB and Tech in prior years, nobody in their right mind could possibly believe the Lege budgeted enough for this line item. One notices that confidence wasn't attributed to anybody willing to put their name on such a ridiculous statement.

At the end of the story, House Corrections Chairman Jerry Madden said, "While we think there are efficiencies that may be realized in the current system, we don't think they should reduce services below what is required. ... I'm sure if they need additional funding, they will come discuss it with us." Well, sir, they already came and discussed it with you: They told you what it would cost to run prison healthcare in TDCJ's Legislative Appropriations Request and y'all slashed it by nearly $130 million. Why would anyone think the Lege would provide "additional funding" anytime in the near future? And even if they ask for more money, the state is broke: Where would it possibly come from?

Texas prison healthcare costs were already among the lowest (per prisoner) in the nation, and the latest budget cut not just to the bone but through it. No matter what discussions happen behind the scenes between TDCJ and legislators (or for that matter, other medical schools), it's clear to me the Legislature is leading the agency down the same path that ultimately caused  a federal court to order California to radically reduce its prison population because of inadequate healthcare. Like California, the Texas Lege wants to cut corrections spending but this session was politically incapable of taking the only action that could realistically achieve that goal: Reducing the number of prisoners incarcerated. So don't be surprised if, given the Legislature's inability to manage its business, sometime in the future the federal courts end up having to do it for them, just like in the Golden State.

27 comments:

sunray's wench said...

Come now Scott, Mr Madden has done his sums and it'll all be fine once all the inmates have paid their $100. Ooops, I mean, the inmate families.

That'll bring in around $160,000,00 and solve the entire crisis without having to release a single extra inmate.

[/sarcasm]

Prison Doc said...

I'm not sure what defines a "constitutional level of care" beyond providing necessary medical care. About 85% of the offenders I see each day don't have any significant medical problem and do not require any treatment, they're just there seeking special privileges or work avoidance. I'm not sure it's "constitutional" but they should be able to seek their remedies from the commissary. One "efficiency" would be to triage these folks to NOT being seen at all. But"constitutional" care currently is requiring everyone to be seen within 24 hours if they desire. Try that with your HMO.

I think UTMB plays a pretty good hand with the cards they've been dealt.

So in our present system we have a bimodal distribution curve--jillions of offenders who are basically healthy and have no needs, and a smaller peak of older sicker inmates who have extensive needs.

No disrespect to Mr. Madden, who seems to be a fine and smart man, but I cannot see how to wring more "efficiencies" out of the current system. Most days we're right there with Sisyphus, rolling that boulder up the hill.

I don't look for any more money out of the legislature in this biennium.

Gritsforbreakfast said...

Prison Doc, the 24 hour requirement is a TDCJ reg, not a definition of constitutional levels of care.

The issue isn't the 85% who you say are malingering but the treatment given to the 15% (by your estimate) with actual medical problems. The actual standard for what is constitutional care was set in a Texas case, Estelle v. Gamble, which read in relevant part (citations omitted):

"We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the "unnecessary and wanton infliction of pain," proscribed by the Eighth Amendment. This is true whether the indifference is manifested by prison doctors in their response to the prisoner's needs or by prison guards in intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed. Regardless of how evidenced, deliberate indifference to a prisoner's serious illness or injury states a cause of action under § 1983."

Then in the case out of California, Plata v. Coleman, SCOTUS ruled that poor care caused by overcrowding can also be unconstitutional. So if you give inadequate care to the 15%, to use your number, because of malingering by others, that could also trigger § 1983 liability. Indeed, I fear that the new $100 fee taken from commissary accounts will make that problem worse. People who were otherwise fine might now feel like they should visit the infirmary because they're "paying for it," even though the amount paid doesn't remotely cover costs.

Finally, I tend to agree with you about triage, but they just cut all those nurses positions so who would do it? Do you trust the guards with that task, deciding whose problem is small enough to relegate to the commissary? Somebody has to physically perform the vetting task, and the Lege simply hasn't funded enough slots to do it.

Prison Doc said...

Grits, I think we can continue to provide a constitutional level of care with these cuts. It won't be fun but I think it will be legal.

The Ruiz decision got us away from having to "bribe" (in some fashion) the Building Tender to get care, and I don't think we are headed back to that.

Federal litigation may once again ensue but I think it is a long way off. As you noted, medical personnel issues is more of a current challenge than the actual provision of care. We can always find anecdotal cases where care was bad, but all in all I think UTMB has done a good job and will continue to do so.

Nurseypooh said...

Prison Doc-I totally agree with you on your 85 percent being, restriction seeking, secondary gain sick call.

How do you feel about prescribing KOP meds to offenders who have a history of abusing or hoarding the medications?
What about just across the board making everything KOP because they layed off most of the med aides in the budget cuts?

How will these decisions affect you at your unit?

sunray's wench said...

If 85% are actively seeking not to work, shouldn't we be asking why that is, rather than cutting the care for the other 15% as well?

Nurseypooh said...

The 24 hours is for someone in medical to triage the sick call, not see them. Please refer to..

http://www.cmhcc.state.tx.us/CMHC_Policy_Manual/E/E-38.1%20(0211).pdf

for the exact policy.

Nurseypooh said...

It's 48 hours to see a nurse/provider/Dr. during the week.
72 hours on the weekend. These are non-emergent health care needs.

If seen by a nurse and she/he determines offender needs to see the Dr. they refer them and will be seen within 7 days depending on the urgent or non-urgent needs of the offender. If the nurse feels the offender should be examined by the Dr. right that day, then the offender is referred for a same day appt. Of course if it is an emergency they are seen right then.

Nurseypooh said...

85% don't want to work due to personal held beliefs that they don't owe the prison system anything and will not work for free. Some feel very entitled to have there needs met without any effort on there own part. Quote: "They locked me up so they need to take care of me and I'm not working while I'm here, I didn't tell them to lock me up." Some have never worked in there life and have trouble adjusting to working. A small percentage have physical limitations and can't perform the work. Those are usually given work restrictions but Dr. such as prison doc for a legitimate claim.

Anonymous said...

Everyone seems to be forgetting now the offenders are CONSUMERS!!! We the family who have paid the $100.00 dollars are the watch dogs now even worst than before because TDCJ/UTMB took my money. That makes the inmates paying customers/consumers. I would think "I" can sue someone simply because now that I have paid and the law of the land applies "that if you pay for a service it is illegal not to provide the service". I know someone at the Crain Unit who was given two appointments at the same time, one to fill out paperwork and one to see the doctor. Guess what it took a week to reschedule and see the doctor because filling out the paperwork was more important. Now by the law of the land and "if you pay for a service you receive a service" this looks illegal. If not than a car mechanic will no longer have to repair cars in Texas after they take your money. I still would like to know what kind of "clown" would schedule two appointments at the same time?

Debby said...

I usually don't comment and to be honest, try not to read other comments but I have a very specific question. I work with folks who are re-entering from TDCJ. I hear that starting in the fall, inmates will have to pay $100to receive health care assistance and if they don't have the money, the funds will be removed from their commissary account until they've recovered the full amount. We put small amounts of funds in selected inmates accounts to purchase writing material to prepare them for job search when they get out. Does this mean that any funds we put in there will be redirected?

sunray's wench said...

Debby ~ absolutely yes it does, if the inmate receiving the funds you donate has an outstanding amount owed to TDCJ for medical fees.

And as an aside, why not comment? Input from all parties makes Grits a good place to discuss issues with others, even if you don;t always agree with them :)

Anonymous said...

Nurseypooh and prisondoc, as someone on the other side of the fence (a former inmate at a female SAFP unit)I have to admit that it galls me to see you both blithely state that 85% of those asking for care don't really need care at all but are just trying to "get out of" something (i.e., work) or get "special privileges" (like a cane, special shoes,a walker).

TDCJ puts people to work in the most heinous of conditions (the hoe squad in hellish temperatures with untrained and dehydrated inmates waving dangerous hoes over their heads as they stand in a line toe to heel with the next one, or perhaps cleaning out the sewer traps with inadequate protective gear, and on and on)--inmates who, though they may be young, have often lived rough, hard lives with poor or no health care and are far more likely to have serious ailments such as HIV,Hep C, cirrhosis, etc than the general population. Quite naturally, the incidence of accidents and ailments will be quite a bit higher than with the average population in the free world.

Inmates injured on the job are fearful of asking to be seen by medical because if a nurse (most of whom nowadays are not professional nurses--RNs--but rather, LVN's with 9-12 months of schooling in nursing, or sometimes just a tech) decides their injury is not bad enough, they are given a case and face punishment on top of injury and owing a $100 bill.

As for "not wanting to work"--the work often assigned by TDCJ is useless, meaningless and nonproductive, such as hoeing fields already hoed or which will not be used for planting, simply as "busywork", or, as happened on our unit, having a huge pile of pig feces 15 feet high dumped on our rec yard and being made to go out there every day in the mid summer heat and take shovels full of feces from the bottom of the pile and put it on the top--again, to "keep us busy". To do this kind of labor in exchange for not one red cent of renumeration--Texas being the ONLY state in the country that pays the inmates not a dime for their labors--when inmates are not provided with even the most basic of hygeine items by the state such as deodorant, shampoo, adequate toilet paper or sanitary napkins, they desperately need at least a small amount of money in order to purchase enough hygeine items to maintain basic health and cleanliness. I was told by a CO to "stick some toilet paper" in my panties because my pad limit had been used up for the month (10 pads). SO yes, I can understand why some offenders might not feel too enthusiastic about doing dangerous, useless busywork in exchange for not even so much as a squirt of shampoo or a few squares of toilet paper.

Finally, charging TDCJ inmates families $100 for medical care is beyond ludicrous and will leave most inmates completely indigent and unable to buy even these most basic supplies, so prison doc's assertion that their needs should be cared for through commissary is otherworldly. I suffered for over a week with a seriously abscessed tooth, was unable to purchase aspirin or ibuprofen from commissary, developed a high fever and was forced to hoe and pick weeds in extremely high heat with a fever of 104 and a very visibly swollen jaw for days before being seen.

It's easy to portray inmates as malingerers who want "special favors" or a lay-in, etc--but when you keep people in these substandard conditions with substandard health care, rampant staph infections and boils, infectious diseases, brutal working conditions, harsh and unethical oversight--who wouldn't need a break now and then?

M. Edwards said...

The $75,000,000 already takes into consideration the anticipated increased revenue. TDCJ is ordered by the state to spend $75 mil less this FY than the last 2010-2011 amount, an 8% reduction.
According to the Criminal Justice Uniform Cost Report dated Jan 2011, presented to the legislature, the average cost per day per inmate in all TDCJ is $50.79, or $18,538 per year. But, the average cost per day for those using medical is $592.96 per day, or $216,430 per year!
If my math is correct, the budget for TDCJ to spend on medical costs is about $937 mil this year, or $5,679 per inmate, all inmates included.
I can not imagine where they will find the savings, particularly if the universities begin to push back.

Gritsforbreakfast said...

M Edwards, you must add to that, though, the tens of millions more that the state underfunded UTMB in the last biennium and paid out this year to make up the hole. As I'd written here:

"Universities providing prison healthcare said prior to the 82nd Legislature that they weren't compensated for $57 million in healthcare services in the last biennium. The Legislature covered last year's shortfall in House Bill 4, but then they slashed another $71.5 million from prison healthcare over the next two years.

"So if the last biennial budget was $57 million short and budget writers cut another $71.5 million without reducing the number of prisoners, the shortfall in the next two years - assuming the same levels of care - would run to $126.5 million, or around $800 per prisoner - a smaller reduction than earlier drafts of the budget but still around a 14% cut."

Anonymous said...

Anon 4:31 PM, Your story has Crain Unit written all over it and for the last ten years I have witness horror stories especially under the last two wardens and the new one looks no better. The guards down there are cruel plain and simply. I have heard them call inmates prostitutes and crackheads at visitation. I was ending my visit and the female guard who I know is a racist yell at my friend "get in there and take everything off now". I thought at least she would be smart enough to wait until I left. This guard hates latino's and whites. She stripped search the inmates before the visits just to ruin the visits for the families. Her strip searches has an agenda because of her life style that she openly promotes in the one unit she works on the Terrace. We the taxpayers pay those clowns just like we now pay for medical twice. My point is I have known for ten years a guard will do nothing to seek medical attention for a sick or injured inmate. The inmates are punished for having a bruise during one of these strip searches or given a case if a medical assistant feels they are faking to get out of work. I have not seen any crops being plainted this year down there but they put them on a hill to cut grass with hoes while some are hit in the head by mistake and on purpose too. Most guards do nothing still. I can only see dead brown grass anyway. I say the guards and medical staff should be charged the $100.00 when this happens. I just had to get this off my chest. It burns me up to hear some one say they are trying to get out of work too. I would too!!! There is no rehabilitation work going on down there nothing but punitive measures. If someone is in school they will stop at nothing to get them kicked out of the classes. Thanks.

Nurseypooh said...

Anon: 431

How do you know you had a 104. temp?
Did you come to medical to be "cleared for duty" when your jaw was visibly swollen and your vital signs showed your temp was 104. ?
BTW I'm one of those (non-professional nurses) LVN.
At the unit I work at, if an inmate comes in to be cleared for duty and I took the v/s and they had a temp of 104., the jaw visibly swollen if dental was not there (which we don't have full time dental) I would have examined your mouth, tooth and gums for swelling, bleeding, drainage etc..... If you had an abcess I would've excused you for duty for a 3 day cell pass which is all I can give you, reviewed your chart for allergies, medical and dental hx., ask you personally if you have any allergies. Contact our provider on site and ask if he could prescribe you some antibiotics for the infection and Ibuprofen for pain, then referred you to dental who won't pull your tooth while infection is present anyway, so by the time you saw dental maybe they would pull or fix the tooth. Before you left I would give you an initial dose of whatever med the Dr. ordered you and give you those little packets of Ibuprofen KOP until your pack comes in, but you will have to come to the pill window for the antibiotics till your pack comes in KOP (I have no control over that).
So that is what would happen on my unit if you were my patient, that is the kind of untrained, non=professional nurse I am.

Non-aspirin is available free of charge from the pickets, housing per pod policy.

Medical has no control of how many pads your issued, the work detail or what the guards do.
A SAFP unit is a "Country Club" compared to a "real prison" like Crain, Hobby, Lane Murray, Mountain View, Hilltop all female units. You were fortunate to be afforded the opportunity to go to a SAFP instead of another "real prison". I hope your experience there wasn't all negative and you gained some skills to use in the freeworld when you got out.

I don't make the rules, always agree with them or pretend some of the things you mentioned don't happen at some units or bad treatment by some guards or medical staff.
I am a nurse who will practice to the best of my ability within my scope of practice allowed by my license. I advocate for my pt.'s wherever I work, use my skills to take care of my pt. and if I can't help them or don't know how to do something I'm not afraid to ask for help, we get the job done and take care of our inmates who need our care.
Prison is not summer camp.

Anon 610-It is tdcj policy to strip search inmates before and after a visit statewide male and female units.

Let the flame throwing begin.
Nurseypooh LVN

Anonymous said...

yes, I am a midlevel provider for a state jail, and yes, I have 2 distant relatives in female state jails right now. I have to agree, approximately 85% of the patients that I see have absolutely nothing wrong with them, I always ask, did you try buying yourself something for this___ rash____cold____ sore knee___headache___over the counter glasses___, the answer is almost always NO. Realistically, would you go to your Dr for 4-6 colds a year? I have a saying, people that are interested and happily involved in life don't go to the Dr for colds, threw up one time, a bug bit me and it itches etc.


on the other hand, I have referred young, healthy males for complaints of urinary frequency, they had bladder ultrasounds, urinary dynamics, prostate ultrasounds, lab tests, camera tests where cameras looked inside the bladder, no abornmalities were found x 3 patients!!!! Now, what could be going on there? I have also had patients who came in and we, lousy UTMB providers diagnosed prostate cancer, HIV, latent syphilis etc. But for being arrested and sent to jail that person would have died.

it will be interesting to see what changes after 9/1/11, as I read the law, if they ask for care, they get care and $100 per year.

I don't mind treating boils etc, many, many of our patients have drug use histories, and if you think this leaves them unscathed I have a road you might like to buy.


Just my two cents

Nurseypooh said...

Anon-914

9-1-11 is going to be a really big day for refusals I'm thinking for those who were trying to get seen before 9-1-11

sunray's wench said...

Nurseypooh ~ I think you have to accept that even though you do your job professionally (as I'm sure PrisonDoc does too) there are a large number of individuals in TDCJ who do not.

People generally like to complain about something. TDCJ simply makes it easier by giving so much to complain about.

However, limiting the number of sanitary pads a woman can have per month is one of the more ridiculous rules TDCJ has. I understand why they have it, but that doesn't make it any more sensible.

Nurseypooh said...

SW, yes I realize it doesn't work this way on every unit, and there are a lot of people who don't do their jobs, abuse the system, mistreat people all the way around.

My opinion is slanted due to my position as is an x offender's, a loved one of an offender, a parole officer, a security officer etc.

Medical has to coexist with TDCJ and try to work together for the good of the unit as a whole and it's not always easy.

Anonymous said...

As of 9-1-2011 they all become paying consumsers!! Get ready for the lawsuits. As far as a strip searches? A strip search is one thing but to have as agenda because of yourt lifestyle is another thing. To call someone prostitutes and crackheads is unprofessional and shows that Gatesville is an area that both profits and thrives on abusing human beings. Those "Real" female prisons you mention are no better than torture chambers. I know guards who refuse to allow inmates to see medical, throw I-60's away and will do nothing when an inmate falls out. I have witness these abuses first hand at visitation for over ten years now. You can hear the strip searches being conducted at the Riverside unit while you sit in the visitation area waiting. We condemmed U.S. Army soildeirs to prison for doing these things in Iraq but do it to females in Gatesville. The SAFP program is a torture program built on abuse, no rehabilitation and punitive measures only. The medical staff at the Crain are taught to abuse these women. Once again what kind of "clown" schedules two appointments at one time and the Doctor comes second? As of 9-1-2011 when that $100.00 is taken and the inmates become consumers you think you have problems now just wait. Now that UTMB personnel have admitted that the Crain, Mountain View, Lane Murray, Hill Top, and the Hell Holes Woodman and Plane are torture chambers I now know I am not seeing things. The strip searches are only to degrade because the only people bringing in contraband is the TDCJ/UTMB personnel. Just ask about the gun that was in the Crain unit recently. A guard bought it in. I wonder why? None of these medical people or security people could get a job no where else in this world. No one would put up with these people. TDCJ/UTMB is employment of the last resort and I can tell by the feathers that were ruffled here.

Anonymous said...

The reason they only give them 10 female pads is so they can look them in the eyes and further degrade them when they run out. This is fun and games to see them without and have blood stains coming through the prison whites. This is all apart of the degrading and humiliating approach TDCJ takes to rehabilitate women. When you assign a TCDJ female guard with an agenda because of a lifestyle she openingly flaunts in the dorms to do strip searches it is degrading and abusive. It is no different than if a male did it. The strip search is the only thing that is done on the Crain Unit that is always defended by TDCJ Regulations. You never hear them spout off rules on anything else. Some of these guards enjoy them and something is wrong with this picture. Just like the male guard who will not let these ladies pull the shower curtain down on the Terrace Unit while they shower. Is there a regulation that entitles this "clown" to watch the women shower and write them up when they complain? Crain Unit is a circus full of clowns.

Anonymous said...

I wish we could discuss what this post was about instead of "female pads" etc.

dfisher said...

I'm sorry I'm late to this post, but I have been busy and this is one of the issues taking my time. On Aug. 9th the murder re-trial of Litrey Demond Turner began in Galveston. Turner's attorney Winston Cochran challenged the legal authority of the Chief ME Stephen Pustilnik based on the fact that the medical examiner never executed his Statement of Appointment or Oath of Office as required by Article 16 of the TX Constitution. The County Judge testified he appointed Pustilnik, but the Deputy County Clerk testified they could not find the Statement or Oath. The Judge overruled Cochran's objection. Today I called the Galveston Co. Clerk and was told Pustilnik executed his Statement of Appointment and Oath on August 11, 2011, which was not a wise thing to do since Pustilnik is a professor of pathology at UTMB. Futher, UTMB pays Pustilnik full salary of $212,000. Under the TX Code of Criminal Procedure, Article 49.25, Sec.3 the county must pay the salary and compensation of the medical examiner and his deputies. If Galveston Co. does not pay Pustilnik's salary, then he would have committed perjury when he filed the constitutionally required forms. So here we have UTMB treating the inmates and doing their autopsies under the guise of a county medical examiner. Anyone other than me seeing a conflict of interest...at the very least?

Anonymous said...

He needs to be in TDC whites!!!!

Isabella said...

People don't leave because things are hard. People do leave because it's no longer worth it.

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