Thursday, April 03, 2008

On the sunny side of the street: Is it time for an independent evaluation of 'telemedicine'?

Since I've posted quite a bit of critical material about healthcare in Texas prisons over the years, I thought it only fair to share what Correctional Managed Health Care E.D. Alan Hightower told the Senate Criminal Justice Committee yesterday are the three most important improvements at TDCJ healthcare since UTMB and Texas Tech took over the system. I personally learned quite a bit from the discussion.

First, the main benefit from operating the prison health system through UTMB appears to be reduced drug pricing. Because UTMB is a state hospital that does indigent healthcare, it qualifies for "340B drug pricing," which dramatically lowers its pharmacy costs. As mentioned earlier, 48% of TDCJ's pharmacy costs go for inmates with HIV. (As an aside, the committee was informed that "Big Pharma" is lobbying Congress right now to end reduced 340B pricing, so it's not inevitable those reduced prices will continue.)

Except for emergencies, all prescriptions in TDCJ are filled in Huntsville at a state of the art, UTMB-run pharmacy using entirely electronic prescription and medical records. Shifting to the cheaper drug prices saved UTMB about $1 million per month. In addition, because all medication is delivered to units in blister packs, unused medication is recycled, saving the state an additional $8 million per year.

In the past, drugs were delivered from Huntsville to outlying units in TDCJ trucks driven by prison trusties, but in recent years it's become more cost effective to simply ship them via UPS, said Dr. Raimer.

Hightower said the second important change for inmate healthcare delivery under the two university systems (UTMB and Texas Tech) was a shift to entirely electronic medical records integration of medical records (upgrading from paper files) into a central system accessible from any unit by medical personnel.

The third big improvement, said Hightower, has been the expansion of "telemedicine," which he said has been invaluable for providing additional consultations at rural units. He and other speakers cited Fort Stockton, in particular, as a spot where the state can't find nurses and doctors, and said that facility was particularly reliant on telemedicine.

In past hearings on this topic, senators had questioned the short amount of time spent per patient in a telemedicine setting - about seven minutes per patient, on average. This time Dr. Ben Raimer came prepared with better answers to such questions. He pointed out that TDCJ and UTMB operated chronic care clinics for a variety of specialized ailments, including HIV, mental health, liver and heart disease, and diabetes.

For those chronic ailments, he said, inmates are housed closer to medical facilities and specialists who can help them on an ongoing basis. Raimer said telemedicine was used more as a triage tool (though that seems to contradict past hearings where we learned they prescribe medications in a telemedicine setting), and that more serious cases received more extended attention.

That certainly makes me feel a little better about "telemedicine," which UTMB pioneered and is now marketing in a spin-off company, of all things. To the extent telemedicine really is just a triage tool, it could be extremely useful. As a substitute for on-site medical personnel, though, which appears to frequently be how it's used, seven minutes per patient is just not an adequate consultation for anyone with a serious problem.

I'd still like to see some medical school or other independent academic (not a Texas institution) evaluate the quality of care being delivered via telemedicine to Texas inmates compared to face to face doctor interactions. Is the quality of care at least close to the same? Maybe such studies exist, but I've never seen them, and if Texas prisons have become so reliant on a basically untested methodology, I think it's high time for an independent evaluation.


Anonymous said...

I think Raimer is a bald-faced liar. He'll say whatever he needs to in order to deflect the political heat.

Anonymous said...

The way money is saved on prescriptions is that the cheapest drugs are used, no matter if they are less effective, and other medicines are not used at all. As a Crohn's disease patient, I have experienced the big difference between freeworld healthcare and UTMB. For example, I was prescribed Mesalamine, but received azulfadine, an older and much less effective drug. I never got anything to control the inflammation that occurs with any Crohn's patient. Now that I'm back to the freeworld, I'm getting treatment for a fistula that won't heal, thanks to the care I got from UTMB. BTW, the fistula developed while I was taking the azulfadine in TDCJ.

Anonymous said...

maybe the prescription savings are
a good thing but who among us in the free world would consent to telemedicine? Getting any medical treatment in the tdcj takes months and I still fail to understand diagnosis and treatment by remote control

Anonymous said...

Any medical person can tell you, you have to be able to assess each and every patient face to face to reach a conclusion as to how sick that person is. Usually a good RN can look at a person's eyes and tell whether that person is really ill and sometimes what is wrong with him/her.

Telemedicine from what I have seen, does not begin to examine a person and only looks at x-rays and listens to whatever someone, hopefully a Real Nurse or LVN has written on a record. This is not an accurate examination.

Anonymous said...

It is time for an independent evaluation of ALL the supposed "health services" in TDCJ. They are saving money on prescriptions because they use 2nd rate drugs, when they supply them at all. Telemed services are a poor smoke and mirrors parlor trick for Hightower to please the politicos. Even person to person health diagnostics are frighteningly lacking. People are actually dying frequently from poor or nonexistent health care in TDCJ. This is a crime.