Sunday, March 28, 2010

Should California pursue Texas-style university-based model for prison healthcare?

Here's a little more detail on California's deliberations about shifting prison health care to the state university system, modeled after Texas' example and promoted by a company affiliated with UTMB, from the Associated Press:
The University of California will form a special committee to study whether it should take over inmate health care for the state's troubled prison system, the chairman of the university system's Board of Regents said this week.

Regents Chairman Russell Gould announced the committee, which university officials said will study issues including the cost, effect on labor relations, and the university's liability in inmate lawsuits. Health care has been so bad in the state's 33 adult prisons that a federal judge appointed a receiver in 2006 to make improvements.

A study by a company affiliated with the University of Texas has criticized the receiver for running up costs as part of the improvement effort. It projected California could save more than $4 billion over five years and $12 billion over 10 years by shifting control to the University of California.

Federal receiver J. Clark Kelso would not comment, said spokesman Luis Patino.

NuPhysicia, the UT-affiliated company, said the university system could improve care and efficiency by hiring the prisons' doctors, dentists and other medical workers, and by providing other care through video hookups that link university physicians to their patients. The study also promoted electronic record-keeping and centralized hospitals to cut costs.

NuPhysicia grew out of the telemedicine programs at the University of Texas medical branch, where UC's senior vice president for health services, Dr. John Stobo, was president. Stobo was the non-executive founding chairman of NuPhysicia's board of directors, which has raised conflict-of-interest concerns.

The Board of Regents said Stobo never received money from NuPhysicia and cut all ties to the company when he left Texas in 2007.

Gov. Arnold Schwarzenegger supports the UC proposal as a way to bring costs for inmates' care closer to those in other states. California currently spends $2.4 billion annually on prisoners' medical care, close to a quarter of the prison system's $11 billion budget.

"This is radical surgery on a broken system that will save the state billions," said Schwarzenegger spokesman Aaron McLear.

The NuPhysicia study said California spends more than $41 a day on health care for each of its roughly 160,000 inmates, compared to less than $16 per day in New Jersey and around $10 in Georgia and Texas. All three states have similar arrangements with university systems there.

The company's telemedicine systems could yield the biggest cost savings in its California proposal by reducing face-to-face meetings between doctors and inmates.

Until UC System vice president John Stobo, who was NuPhysicia's board chair when he was president of UTMB, chose the company he helped found to advise the university, NuPhysicia was marketed as a telemedicine service provider, not a policy consultant. But now this private company, which spun off from UTMB with the university as a formal partner (with a 35% stake), is promoting a telemedicine based system in California that, oh by the way, is the primary service they were created to market. Fancy that.

The model NuPhysicia is promoting: Providing video hookups at prisons so doctors at university medical schools can "examine" patients from afar without ever sullying their schedules with prison visits. That's what Texas does at our state prisons, but the system hasn't been as great a success as one might hope. The system failed so miserably at the Dallas County Jail it cost UTMB their contract. When UTMB managed Dallas jail healthcare, as Grits noted in 2006, "For every month spent in the Dallas County Jail, you're more likely to get a staph infection [3.4% chance] than you are to hit 'snake eyes' when playing craps in a Vegas casino (~2.77% chance). Wanna roll the dice?"

Later in 2006, UTMB officials told the Sunset Commission that doctors providing care via telemedicine to state prisoners see 60 patients in eight hours, typically in shifts from 4 a.m. to noon. As a doctor in the Texas Senate pointed out at the time, that amounts to roughly 7 minutes per patient:

Sen. Bob Deuell from East Texas, who is a medical doctor, sounded skeptical of the telemedicine system. He questioned during the Sunset hearing how high the quality of care could be for patients who only saw their doctor that short a time and only over a video feed.

Those sorts of official descriptions of Texas' system led this blog to observe in 2007 that "'Telemedicine' is the physicians' version of fast food, a cheap, industrial, low-quality product that promotes dehumanized social relations for both health workers and customers." It's arguably good for some things and not others, but nobody's taken the time or done the outcomes-based testing to determine the difference. Instead, the tactic is treated as a cure-all when at best it should be a supplement to traditional hands-on care.

I've thought from the get-go that UTMB should make telemedicine work better in Texas before exporting the idea elsewhere. At a minimum, before California follows Texas down this particular garden path, it'd be good to see independent evaluations of UTMB's system instead of only self-interested, vendor-driven analyses from NuPhysicia.

There's also a more fundamental question regarding the conflicting missions of med schools and corrections agencies and whether joining these institutions at the hip could negatively effect the culture of either or both institutions.

Has UTMB's stewardship of prison health services worked well in Texas? Can we sufficiently document positive results to the point where we may confidently suggest exporting these methods - particularly telemedicine? Color me skeptical. After all, Texas hasn't worked out all the kinks in our own system. California officials should look long and hard at this proposal and get a second opinion before taking Dr. Stobo's and NuPhysicia's advice about copying Texas' model. A university-run prison health system hasn't solved all Texas' problems and has sometimes created a few.

See related Grits posts:


BB said...

Most of us feel as if we are fortunate when our PCP spends 7 minutes with us. Texas has 63 general med docs for every 100,000 people compared to the national average of 81.
You should here the stories about members of the offender population who visit with a UTMB provider via satellite and then stand up at the end of the visit to shake the docs hand. It happens more often than one might think.
Telemedicine is a good thing.

There is also so much that you do not know about the Dallas county jail partnership. You be proud of UTMB if you knew all the facts of this particular experience.


Anonymous said...

Talk about a one sided blog. Before you slam telemedicine, you should have all of your facts straight. Your blog is misleading..

There are doctors and providers serving behind the gates on Texas Units. UTMB leads the way in Correctional managed care.

Gritsforbreakfast said...

Hmmmm, what do both these comments have in common? Both a) claim special insider knowledge, b) are anonymous, c) cite no sources, d) reference no specific facts, but e) want us to take it on faith, without independent verification of any sort, that telemedicine is a good thing and UTMB managed care works great.

Tim Cole and others like him might tell a different story, if they were around to do so.

Anonymous said...

Dave, a former inmate says...I hope California does not go to anything like UTMB, and I am speaking from experience. For 10 years I was at the mercy of the doctors and PA's to help me manage my Crohn's disease. I was in remission when I got locked up, but as can be expected with the stress, I started having problems. The UTMB doctor (whom his colleagues nicknamed "Dr. Death" but that's another story)did not believe I had any problems. It wasn't until that buffoon was escorted off the unit (too many lawsuits filed against him?) and a PA came in did I get any treatment, but then it was only with an older, cheaper medication called Azulfadine. There were better treatments available in the freeworld such as mesalamine and Humira had just been approved, but I could not have them because of the cost. I later got mesalamine when it became apparent that the older medication was having no effect and my health continued to decline. Eventually I needed surgery but did not get it because I was close to my release. Now that I am out, I continue to have problems that I think could have been avoided if I could have had proper treatment and or surgery. As for telemedicine, what a joke. May God help the CA inmates if they use the TDCJ model.

BB said...


I am very disappointed in you. All negative outcomes cannot be prevented. Sometimes bad things happen.

Let that man rest in peace.