Tuesday, July 10, 2012

Health clinic hours reduced 50% at some Texas prison units because of budget cuts; Ogden says prison health budget underfunded 15%

Clinic hours at some Texas prison units were cut by up to 50% in the wake of recent budget cuts, Texas Tech officials told state senators on Monday.

The Texas Senate Finance Committee met yesterday to address correctional managed health care. Go here to watch the hearing online. The only MSM coverage appears to be from Chris Tomlinson at AP. The money quote from that story: "Dr. Denise Deshields, the health director of Texas Tech University's prison health care system, said the new cut could lead to an unconstitutionally low level of care. 'I don't know how we would possibly handle an additional 10 percent reduction in appropriations. We are really cut down to the bone as it is,' she said."

Further, "The vice president for offender health services at the University of Texas Medical Branch, Dr. Owen Murray, said that because of staffing cuts guards are now expected to help make medical decisions that nurses and doctors once made."

Grits listened to much of the hearing this morning. Here are a few tidbits the abbreviated AP story didn't pick up:

Chairman Steve Ogden openly prefaced the hearing by declaring, "We did not last session appropriate all the money that we believed was going to be necessary to pay for correctional managed health care. There was a great deal of concern at UTMB that we might run short and they'd be left holding the bag." Grits readers knew that but I hadn't heard an elected official says so that openly before now. (One supposes it helps that Sen. Ogden is retiring and won't be back next year.)

Ogden emphasized that there's a contract in place with UTMB through next session, but not through the end of the biennium. Right now it looks like the state may be short by $58 million, he said, which would have to be paid for with an emergency appropriations bill at the beginning of the 2013 session. There's "no crisis at the moment," he stressed.

In fact, Ogden said that when the Lege adjourned, budget writers thought they'd shorted prison healthcare by "maybe $120 million" (Grits' calculation was $126.5 million), so if it's only $58 million, in some ways it's "good news," Ogden suggested pluckily (particularly if you like your good news written in red budget ink).
 Sen. John Whitmire wanted to know, if TDCJ now will be $58 million short instead of $120 million, how was the money saved? He worried that the state may have saved money by reducing services to the point that we have an unconstitutional system, and if so that it might cost more in the long run.

Whitmire scoffed that UT comes up to him and says they're going to "walk it" (the contract"), their board says they're going to "walk it," but when the media asks him about it he replies, "Naw, they're not gong to walk it ... we have  nothing to replace them with." At this point, though, negotiations are ongoing and the issue is unresolved. Senators Whitmire, Tommy Williams and Robert Duncan have all been closely involved with UTMB negotiations, said Sen. Duncan in his comments. (Texas Tech, it should be mentioned, is fine with continuing under their current contract: UTMB is the only one threatening to quit.)

LBB staffer John Newton gave a rather dry, just-the-facts-ma'am, presentation. Sen. Royce West brought up a big sources of savings for TDCJ prison healthcare that no private provider could replicate: In particular, UTMB has access to so-called 340B pricing on its pharmacy services, which is pricing only available to institutions that operate a hospital eligible for "disproportionate share" funding for provision of indigent services. Indeed, even Texas Tech is not eligible for 340B pricing, the committee was later told. (It's one of the reasons Grits has been skeptical at claims privatization might lead to significant savings.)

For a variety of reasons, healthcare for inmates is far cheaper than for state employees or under private insurance, LBB staff told the committee. Sen. Whitmire pointed out that part of the reason it's cheaper is they deliver fewer services. For example, "at 7 o'clock, [prison doctors] go home, to save money ...  so if you get sick at 10 o'clock in the free world, you get health care. In prison, you wait" till the next morning, "or don't get it."

Senators seemed amazed that California's cost per day was four times Texas', according to data provided by LBB, but they did not get good answers on what's happening in California vis a vis federal litigation over healthcare, so I should point out that it's a question Grits has addressed in some detail in the past. It's also worth noting California's baseline costs are higher: Prison guards make around twice what ours do, for example.

Sen. Duncan asked several times if Texas is providing a constitutional level of care, but he didn't press for a preferred answer. He pointed out that Texas had been under a court order in the past, and said he wanted to know if the state was still providing a constitutional level of care now that the state is out from under federal oversight, implying the state risked additional federal intervention and by extension, California-style cost increases. California has three state-run prison hospitals, LBB noted, which were expanded recently to comply with federal court orders, as well as relationships with numerous contractors for health care services.

The idea of expanding Medicaid eligibility to cover certain prisoner hospital stays was discussed, but dismissed. Currently most of TDCJ population would not be eligible for Medicaid, even if they weren't incarcerated, except for pregnant women and certain blind and disabled inmates, said LBB's Newton. If the state chose to expand Medicaid under Obamacare, however, most prisoners would be eligible in FY 2014, or at least they would be once they're back in the free world. And even while in prison, Medicaid could pay for some of their hospital services. However, LBB's Newton gave the best argument I've heard against extending Medicaid to cover prisoner hospital stays: That approach may be more appropriate, he said, in a fee for service setting than under a managed-care contract, undermining incentives for providers to limit hospital costs. (The point soon became moot as elsewhere yesterday Gov. Rick  Perry came out against expanding Medicaid at all.)

Dr. Cynthia Jumper (associate dean, Tech) touted the benefits of telemedicine in reducing travel costs and access to specialists in facilities like Dalhart. Even so, she said, budget cuts last year resulted in reduced clinic operating hours at clinics managed by Texas Tech: Nine units operated by Tech cut operating hours by 50%, she said, and 11 others cut operating hours by 25%. (Emphasis added.) Tech already cut 77.39 FTEs (full-time equivalent staff positions) as a result of the 2011 budget cuts.

Texas Tech's budget was reduced by $25 million over this session, noted Sen. Odgen, asking what they would do with that money if they got it back. Jumper disappointingly answered, hire more staff and pay existing staff more money. A better answer (which Sen. Deuell tried unsuccessfully to hand them) would have been to fill staff vacancies and expand clinic hours to past levels, thus reducing emergency room costs. After all, inmate patients go to local emergency rooms if they get sick after hours, according to testimony, and the state gets a bill for those services.

Other reduced services under the Tech system included closed ICU beds at the Montford Unit and canceled after-hours services for certain special-needs inmates. Tech officials also testified as to the difficulty of getting hospitals to agree to Medicare rates because of extra security costs. Some providers have dropped out, the committee was told.

Tech has a 17% vacancy among professional staff and already find it "difficult to recruit, difficult to retain." In particular, pay for nurses is already below market. Tech officials said they did not think they could provide constitutional levels of care if they took another 10% cut.

UTMB was represented at the meeting by Dr. David Calendar and Owen Murray, VP of Offender Health Services. UTMB reduced its number of employees by 165 FTEs under new staffing plan negotiated with TDCJ, Dr. Murray told the committee. They also cut hours at on-site clinics - in particular it was mentioned that 14 UTMB-run clinics went to eight hours per day from 12 hours or more - but not as radically as at some Tech-run units. Instead, cuts on the UTMB side were mostly focused in management and mental health services, the committee was told. In addition, cuts to facility support personnel have resulted in noticeable declines in productivity. Murray said there were probably some "critical staffing needs" where the agency "cut too deep." When the Correctional Managed Healthcare Committee was created, Dr. Murray pointed out, clinics were open 24/7 at all units.

Primarily, savings from last year's budget cuts occurred because of reductions in personnel and reduction of services, said UTMB officials. There were also some savings in reduced emergency room costs because hospitals including UTMB must now accept Medicare rates instead of the amount they charge insurance companies.

Many of Senators Ogden and Dan Patrick's questions seemed aimed at prodding respondents to rebut the implications of Sen. Duncan's questioning to say affirmatively that the state provided constitutional levels of care. Ironically, the go-to answer they solicited from several officials (besides buck passing) was that Texas' level of care met American Correctional Association accreditation standards. But the state chooses not to follow ACA standards when it comes to, for example, heat in prison units, according to a report over the weekend. The Statesman's Mike Ward cited "American Correctional Association standards that stipulate temperature and humidity inside prisons be kept at 'acceptable levels.' A state law mandates county jails be kept between 65 and 85 degrees, though it doesn't apply to state prisons," Ward reported.

I'm not a lawyer, but if the state is going to claim compliance with ACA standards means their prison health care is constitutional, they may find themselves hoisted on their own petard if and when litigation goes forward regarding heat-related deaths at units that don't meet ACA standards. Grits reported in June on oral arguments at the 5th Circuit on whether federal litigation can go forward to decide if excessive heat violates civil rights.

In any event, Murray told Sen. Dan Patrick that reducing clinic hours put non-medical personnel like guards in the position of making medical decisions. When medical personnel aren't there, the state incurs costs at local emergency rooms they wouldn't otherwise have to pay, resulting in more costly, excessive and inappropriate care overall.

The private vendors hoping to take over TDCJ health services said they would likely hire on most existing employees but cut their benefits, especially pension and retirement services.

Brad Livingston, TDCJ executive director, seemed hopeful if not sanguine that UTMB might continue to contract for services "in the long run." If prison health is privatized, he said, the Lege should plan to pay a significant amount for compliance monitoring in addition to the contract costs and demand strict compliance with staffing minimums at the units, particularly those in more remote areas.

Sen. Ogden got LBB to acknowledge that quite bit of state spending on inmate health care and prisons generally - particularly employee benefits - are  actually outside of TDCJ's budget. (The Vera Institute of Justice recently calculated that 23% of Texas prison costs are outside TDCJ's budget.) He asked for LBB to come up with a total calculation going forward that includes all those off-budget items, as well as UTMB's overruns, which will be interesting to see later on. Ogden offered his own opinion that, when such an analysis has been performed, the actual cost of prison healthcare will be about 15% above what the state has appropriated. I'll betcha he's pretty darn close.

The question is, knowing that, how much longer can they kick the can down the road? Texas' costs per prisoner on healthcare aren't getting much lower and, if Ogden's right, they are understated. The only way in the near term to reduce prison health costs further is to 1) reduce the number of prisoners or 2) reduce services, possibly to the point of risking California-style litigation, where federal courts ordered tens of thousands of prisoners released. Better to choose to reduce inmate numbers thoughtfully on the front end than to chronically underfund health care and hope different judges on SCOTUS will decide some future Texas prison health care case.


Lee said...

Scary Words: "The vice president for offender health services at the University of Texas Medical Branch, Dr. Owen Murray, said that because of staffing cuts guards are now expected to help make medical decisions that nurses and doctors once made."

I thought you had to complete medical school and pass the medical review board to practice medicine.

I smell a lawsuit coming only after a few preventable inmate deaths.

Prison Doc said...
This comment has been removed by the author.
Anonymous said...

Nothing that a nice deadly prison riot won't fix...

Anonymous said...

For the smaller units, when they shortened the clinics to 8 hours instead of 12 they relocated the diabetics, seizure and hiv patients to units with 12 hour coverage. This has really overburdened those units who were barely getting by before the increase in chronic care patients. I know this also affected security staff as there were increases in transports to the local hospital after hours for these offenders, not to mention more than have of the unit going to pill window.

Anonymous said...

There is so much here to comment on I hardly know where to begin. I guess the best place to start is with some of the content I don’t agree with.

Dr. Murray said, "That because of the staffing cuts guards are now expected to help make medical decisions that nurses and doctors once made". On the surface of it, this remark makes it sound as if TDCJ Officers are determining patient care. This statement is misleading. They present a patient on the DMS, (put a patient in front of a camera for a medical provider to view on a monitor and talk with), or they talk to a medical provider on the phone and tell them what the patient's complaints are. Better yet, they can and should put the patient on the phone for the provider to talk to directly. The provider makes the triage decision and directs the officer on what to do. Those choices are; call 911, take the patient to the ER by van or have him see the nurse in the morning. If the officer can not talk with a medical provider or they feel they don't have time, they can error on the side of caution and send the patient to the ER by van or call 911. They are helping but, if they make any decision at all it is to just take no chances and send the patient to the hospital. This is a far cry from playing nurse or doctor.

At present there is a contract in place between UTMB and TDCJ for medical care. That contract was signed some time after last Christmas because UTMB told TDCJ they would no longer agree to month to month contract extensions. So, TDCJ took 46 million dollars from their FY 2013 budget to extend the contract. That contract runs out August 31st of 2012. UTMB told their employees they have an agreement to keep working until May 2013 but, there is not, at this present time, any contract to cover that time period.

Will UTMB walk out on the contract? First, there is no contract at present after August the 31st of this year. Two, Dr. David Calendar is on record as saying he welcomes TDCJ to send patients to UTMB's John Sealy Hospital but, he does not want to provide care at the prison facilities. The reason is simple. Providing care at the unit level is not profitable any longer. The point here is that UTMB is not going to use education funds to pay for over runs providing care for Texas prison inmates. Even if Dr. Calendar wanted to do it, it is very probable that the UT Board of Regents would not allow it.

Why would UTMB be expected to pay for over runs in prison health care? To answer this question you have to go back to the way UTMB used to do business. UTMB used to agree to a contract knowing it was under funded. Then UTMB would pay out of their own pocket for over runs incurred providing care. When the time came UTMB would request the Legislature give them supplemental funds to cover the over runs and the legislature wrote a check. Business was done this way for years. Then the bottom fell out and UTMB was told to do it for the amount agreed upon.

Senator Ogdan says, "There's no crisis at the moment". Let's see now; we have gone from all UTMB units providing medical care 24/7 to severe cutbacks on the hours of operation for many units. There are very few 24/7 units left and they can not always be properly staffed. For that matter there is a staffing crisis at almost every unit and for a number of reasons to long to list here, it's getting worse. I don't know what the behind the closed doors politics are but, don't count on UTMB not walking. To be continued...

Anonymous said...

Anon 500 continued

Add to that the system is looking at another 10% reduction. Now let’s add the wild card. What happens if Texas is forced to provide A/C?

Saying "unconstitutionally low medical care", means what exactly? By that if you mean that prison inmates have a right to medical care that is federally mandated and Texas will be looking at another Ruiz case if this under funding continues then I'll agree, that it's low all right. There have been many bad patient outcomes already. One day, one will provide a good test case and Texas will be standing tall before a Federal judge again. As far as ACA accreditations go, don't count on that to save the day. I'm sure it will be used in a defense but...? Besides the public has no idea what a joke an ACA accreditation is anyway, at least for medical, maybe for security it means something, I don't know. That's a whole other topic to be detailed if needed at a latter time. What a mess!

Yeah, Texas is putting out $7.75 a day, an inmate for prison medical care and California is about $40 a day and if this isn't fixed it's going to be, "should of paid now because you won't believe what it's going to cost when a Federal judge gets rolling".

Anonymous said...

"Instead, cuts on the UTMB side were mostly focused in management and mental health services, the committee was told."

UTMB Correctional Managed Care, like the state as a whole prefers to cut mental health care. Who needs it? They don't believe mental illness is "real" illness anyway.

Gritsforbreakfast said...

@9:05, everybody at the hearing including UTMB seemed to agree UTMB would continue its contract through next session, which means essentially till June 1, give or take. There may have been an extension you don't know about.

As for guards making medical decisions, you say "They are helping but, if they make any decision at all it is to just take no chances and send the patient to the hospital." That's EXACTLY what they were talking about at the hearing. Having those inmates screened at the prison by medical staff and treated on-site whereever possible is FAR cheaper than sending them to the local ER, with security, and getting a bill from the county, hospital district, etc., later. ERs are far and away the most expensive setting to deliver routine care.

Finally, I agree that in the end this may be a power dispute between the UT Board of Regents and the Legislature, no doubt. But since the Lege holds the purse strings and universities are already under budgetary siege, it's sure a risky gambit for UTMB to engage in this sort of brinksmanship. IMO, either they eventually plan to acquiesce in the contract or else they REALLY haven't thought through the consequences of snubbing the Lege and leaving them hanging out to dry, which would be the net effect of "walking" the contract.

Anonymous said...

Really we don't disagree.
Understand UTMB is bleeding staff at the unit level and turn over is very high, for reasons to long to list here. However, the main point is, as you can imagine, people want to feel secure in their jobs and morale could not be worse. Those who can retire are doing it. Those without enough time vested to stay on though all this are quitting because, the pay is so far behind the free world. In the past UTMB has always set land speed records telling the rank and file about contract extensions since, they have every motivation to do so. If there is an extension to June 1st I sure can't think why they would keep it secret. Maybe there is an extension I don't know about. However, at present, UTMB-CMC has told staff they are staying on till June but still the contract ends the last part of August.

I am painfully aware what offsite care costs are and you are right allowing security to call the shots and send people out is expensive. Sure it would be better to have a nurse on duty at every unit all night long and once upon a time they were. Before all this nonsense got started and it was decided to underfund prison care there were nurses at all the units 24/7. I was just pointing out that security officers were not assuming the roles of nurse or doctor in such a way as to be guilty of practicing medicine without a license. You have to be careful what you put out there as people think the worst of the prison system without fueling the fire.

Will UTMB walk out? In the end after all the posturing is over, I think UTMB and the legislature need each other whether they like it or not but, a bunch of changes will have to be made to come to a contract agreement. This is a whole other topic for another time.

Prison Doc said...

What he said.

I think UTMB will be in for the long haul, but I can only imagine a few scenarios that will work:

1. State give UTMB the millions they seek--won't happen.

2. State release all the people who don't need to be locked up--drunks and druggies, 19 year olds who dated 15 year olds, non-aggravated property crimes, etc.--not likely to happen in one fell swoop

3. Top-down reorganization of all prison health care in both TDCJ and UTMB systems to remove the deadwood and inefficiencies--this is a monumental task that probably can't be done in house, but will need to be done if a functioning system is to be rebuilt. Judge Justice and Vincent Nathan did their best, but time moves on and there are better ways to do things.

I hope positive changes will occur, and soon.

Anonymous said...

UTMB has focused cuts on mental health and management. Management!? Yeah right! Management at the facility level is what was cut. Through every RIF no position at the Division level was ever cut. The units were gutted until there was practically no one for middle management to supervise but, those guys went right on collecting their way out of line salaries. Why would they RIF themselves - go figure?
TDCJ is painfully aware of their salaries and the unnecessary drain they are on the money needed for prison health care. Now that Linthicum and company are calling the shots they are really excess baggage.

Anonymous said...

" Big Texas News " Just like when my dog got a taste of killing chickens, he never stopped. An inmate is like my dog, you feed it and house it, it will always come back. Comitting a crime is easy work, they will not work. Same as my dog they will always keep killing chickens. Untill they are caged

Nurseypooh said...

Nurseypooh is one who is leaving the prison system to move on to heopefully greener pastures. Going back to school. The demand of work they are putting on all staff, nursing, med aids, CCA's clerks is astronomical it gets worse every day! We are all tired, disgruntled, drowning! They continue to ask us to do more with less staff so if we do what they're asking us to, something else will not get done like all the nnnn paperwork we have to do. I do the best I can and they still want more, my days off are not days off anymore they are spent in my recliner in a vegatative state trying to rest up and recoop before I have to go back to another day of constant running, without a breath of fresh air except when I have to go rescue an inmate in the bldg's and they get focused on because they are the top priority at the moment then all the inmates in the waiting area wonder and are cussing and c/o because nursing is not see them in a timely manner Not all of them actually some of them are reasonable and see what we're doing. As I said we are drowning!I have a choice to swim out of the sea of hopeless despair and I am!

Anonymous said...

I am a UTMB-CMC employee. I love my job and I love the people who work with me. I'd like to retire in 15 years while still under this contract. I'm saddened by the turmoil that the ongoing budget crisis has created and how good people have left the system, and continue to do so, for that reason and many others. Unit staff are bitter, tired, and disgruntled, primarily because they aren't paid near enough money, but also because they feel it's a constant patient care battle that they're losing. The Lege should adamantly request input from line staff and unit providers to determine what may be the best course of action. Well, we all know that will never happen. One thing is certain, though. It's becoming harder and harder to get doctors and dentists to work in remote locations for low pay and lots of driving. The reckoning is imminent.

Anonymous said...

Nurseypoo you will be a big loss, obviously you are one of those who knows which end is "up". Yes they need to fire the high dollar people in Galveston and Huntsville and provide more care at the units. So far all of the cuts are made at the units and all they do for the units is add more paperwork requirements.

Anonymous said...

I am also a UTMB-CMC nurse employee. As much as I am going to hate looking for a new job, (everybody does), I also will be leaving. I too love the people I work with everyday but, there is hardly anybody left anymore. Here my reasons for getting out.
● The pay has fallen way to far behind the market. We have not had a pay increase for 4 years. Because of new taxes, and soon there will be more, my take home pay has fallen. Also, there is very little room for advancement.
● Although I like the people I work with I can't stand the UTMB-CMC upper and middle management. I am not alone in this. Just look at the U-Count Surveys over the years especially the last one. Upper and middle management's approval rating is less than 10% over all. When asked, "do you trust them", it's less. No one trusts upper and middle management. They withhold information and have a history of putting procedures in place that don't function. It's sad that a blog like Grits is often our best source of information.
● Between TDCJ's new found power to direct policy and procedure and the ever present total micro management of UTMB-CMC the paperwork requirement to treat a patient is staggering. Everything is tracked and audited. This was a giant task even back when we were appropriately staffed. Now it is impossible and getting worse.
● UTMB and TDCJ have historically never gotten along. There are areas where each side could improve and compromise but, they have never been able to do so in a way that would make a difference. This constant in fighting always effects the work environment at the unit level in a negative way.
● The contract with TDCJ is up at the end of August. Although UTMB has told us they will stay till next June of 2013 nobody trusts them. Really anything could happen.
● Staffing is so low, it puts everybody's license in jeopardy. If I stayed I would ask the nursing board for safe harbor.

Working in prison has never been a picnic and things have been bad for years but, now it's too much. There is no money, no leadership and UTMB and TDCJ can not get along to work together in any meaningful way.

Anonymous said...

Nurseypooh, good for you. I quit recently and I am a new person. Now that I have been gone awhile I look back on it and wonder why I put off leaving so long. There are real nursing jobs out there that require real patient care skills. It has been so long I forgot what a rewarding job nursing can be. I rediscovered why I became a nurse in the first place. What's really great is my job doesn't require that I spend most of my time documenting the proof I gave the care.

Unknown said...

Yes, Nurseypooh will be a big loss. There have been many before her who were also a big loss. The fact is the old guard is leaving and those hired to take their place are good nurses but, correctional nursing is a special skill and takes some time to adjust to. The public thinks that the only reason a medical provider would work in prison is because they are not competent and probably couldn't work else where. Nothing could farther from the truth. It's takes a special person to work in the prison environment. It's a hazard, stressful and believe me no one thanks you. You receive no consideration from the patients and anything you do, even if it is 100% right, gets taken apart looking for a mistake. Any treatment you give is under a microscope. In an emergent situation there are officers filming your every move. I wonder how ER personal in any hospital would feel about that. Oh, I forgot that’s not allowed any place except prison.

Nurseypooh said...

Thank you for all the well wishes and amen to all the recent comments made I couldn't have said it better. Correctional care is a thankless job but I actually do get thanked quite often when I help someone who is actually sick and do my best to get them the care they are entitled to they are very appreciative but I'm just doing my job. The ones' that usually cuss me out are the ones who are in there for secondary gain and there is nothing wrong with them, I call them on it and they don't like getting caught or not getting what they want.