Cutting Cost Associated With Arizona Inmate Medical Transport System

Creative Solutions to Maintain Public Safety & Provide Efficient Care for the Prison Population

Abstract

The following report was prepared for Sam Lewis, the Director of the ADC. The report and its recommendations are designed to identify improvements in the inmate medical transport system that could lead to cost savings. The report encompasses a wide range of recommendations and their possible constraints.

TABLE OF CONTENTS

ABSTRACT
EXECUTIVE SUMMARY
INTRODUCTION
CONSTRAINTS ADDRESSED BY SOLUTIONS
SOLUTIONS

-Improve the medical facilities of Florence Prison
-Utilize work-training programs to cut costs
-Hold monthly clinics for non-emergency exams at the prison
-Invest in Electronic Medical Records
-Telemedicine
-Contract outside medical care
-Inmate Co-Payment/ Fee for Service
-Adopt preventive health care programs

REFERENCES

Executive Summary

The continued pressure for imprisonment combined with the need for budget cuts in the Arizona Department of Corrections (ADC), demands that the ADC find creative solutions that can both maintain public safety and provide efficient care for the prison population. The focus of this report is narrowed to solving the most severe issue of medical transportation cost. The ADC spends just under two million dollars on transporting prisoners to outside medical facilities. Many of these transport costs were for prisoners having to make one time trips. 3,195 inmates were transported one time due to the necessity of medical care caused by the lack of facility within the prisons. These transportation costs tax the resources of the ADC because they require increased security and reallocation of human resources which often demands overtime be paid in order to facilitate the transportation of prisoners.

Some of the major contributing factors to the high cost of transportation are due to the nature of the prisoner's medical needs. Prisoners typically have a larger requirement for medical services. Many prisoners have chronic conditions such as HIV or diabetes which require that these individuals have medical supervision. Prisoners are prone to serious injuries, especially in the more violent offenders and this requires increased care from outside sources. Prisoners also try to use medical services for other purposes such as escape or even escaping the monotony of prison life. While these issues have been controlled through tight security measures, the cost for this security has been taxing on the ADC.

The prisoner transportation process is further increased in cost due to the complexity of factors within the prison. Prisoners will refuse treatment, creating delays and other time-consuming issues. Corrections officers are often resistant to dealing with the medical transport of prisoners because it seems unfair that prisoners should receive medical care for free when the officers must pay for their benefits. These factors create an expensive and ongoing cost issue with medical transportation services in the ADC.

There are a variety of solution constraints that surround the medical transport cost issue. These constraints include:

1. Inadequate medical facilities within the prison require 5,000 trips to Maricopa Medical Center.
2. Inefficient transportation of prisoners, averaging 1.89 inmates per run.
3. Prisoner malaise towards healthcare creates delays and increased cost.
4. Inefficient administrative practices requiring redundant scheduling or rescheduling create cost increase.
5. Costs of Vehicle Operation $201,994
6. Public Safety Concerns and Security Issues require increased correctional officers and other human resources.
7. The different security level of prisoners requires different protocols when transporting (moderate, medium and maximum security inmates).
8. Overtime Pay for medical transport officers cost $1,730,384.
9. Healthcare is required by law for prisoners.
10. Costs for services continue to rise as the prison population continues to grow.

There is a variety of solutions that may be implemented singularly or in conjunction with one another in order to alleviate the cost of medical transportation. These solutions vary in cost and in the long-term application. The solutions include:

A. Improve the medical facilities at Florence
B. Utilize work-training programs to cut costs
C. Hold monthly clinics for non-emergency treatments at the prison
D. Take advantage of recent advances in electronic medical record systems
E. Telemedicine
F. Adopt preventive health care programs

While many of these solutions are expensive to implement their long-term benefits would be much more economical. By virtue of the prison life and the chronic nature of many on the illnesses that are present the most efficient solution would be to improve the medical facilities at Florence. This is of course a long term solution that would almost entirely remove the need for medical transportation. This solution coupled with smaller programs that are more preventative in nature would be the most efficient use of funds and provide the most sustainable economic solution.

An improvement of the existing services at Florence shows a more economical solution. The implementation of certain basic services within the prison would have reduced cost by nearly half. The ability to provide basic orthopedics, x-ray, and eye services, would have reduced the number of inmates transported to outside medical facilities by 45%. This would have reduced the number of prisoner transports from 4,950 to 2,227.

The cost savings from increased prison services also increases saving by reducing the number of CSO’s delegated to medical transportation duty. The increased service also has the added benefit of increasing public safety by not having to expose civilian populations to prisoners. By not having to transport as many prisoners, security is increased and the chance of escape is significantly decreased.

A comparative cost analysis between the rising cost of medical transportation at Florence and other prison facilities which provide increased in-house care shows the full savings and utility of the solution. At the, Hernando Jail in Florida, a small medical center that is 4,500 square feet was constructed for $1.5 million. The cost of this facility is nearly half of what is spent on medical transportation by the Florence prison.

There are many individuals in Arizona and in other state governments whom feel that privatization is the key to reducing costs. This solution when examined in detail proves to be highly inefficient and costly. It is part of the recommendation of this report that privatization should be avoided in lieu of increasing the medical services at Florence. Several studies have shown that increases in correctional health care costs have been largely driven by greater usage of contract medical services. The use of private services for specialty medical care provided outside prison, private ambulance transportation, and nursing and pharmacy registries, in the California prison system more than doubled in cost across only a few years of implementation.

The most economical and efficient means of lowering ADC costs resides in the increasing of prison medical services. The construction of one clinic on the Florence premise could reduce cost by half and create long term solutions to the transportation issue. This solution provides a variety of economic benefits as well as security benefits. The solution can be implemented over time and works well in conjunction with other less expensive short term solutions such as preventative programs and telemedicine initiatives.

The following report analyzes the variety of solutions for decreasing ADC prisoner medical transportation costs. The recommendations are designed with the focus of reducing cost while still providing the best possible care for inmates as required by law. This report provides the necessary data for the ADC to decide which solutions are most likely to succeed in reducing costs.

INTRODUCTION

Correctional facilities all across the United States have been faced with a dilemma: to provide quality medical care to an increasing number of inmates while dealing with budgets that have been cut and constrained.

The Arizona Department of Corrections (ADC) is no exception, particularly the two largest prison complexes located in Florence, Arizona. The costs and security issues surrounding the transportation of inmates for outside medical care is one area in which improvements to performance could result in cost-savings for the ADC as more budget cuts are absorbed.

This comprehensive report will discuss several possible solutions for ways in which medical transportation of inmates from the two prison complexes in Florence to the Maricopa Medical Center (MMC) could be improved to cut costs while preserving security.

It is not possible to avoid transportation for offsite medical care all together. This report focuses on solutions that find a cost-effective balance between on-site resources and off-site care. CONSTRAINTS ADDRESSED BY SOLUTIONS

Solutions are only viable options if they address the constraints of a problem. Due to cuts in the budget, the ADC correctional facility in Florence is faced with several constraints while seeking ways in which to cut costs. Namely these constraints are:

1. Inadequate Medical Center at the Prison Complex requiring Off-site Care

o The medical center located at the Florence prison complex is not capable of handling particular medical services, requiring nearly 5,000 medical transportation trips of inmates to Maricopa Medical Center (MMC) 75 minutes away in 1991.
o Transport vehicles are not always full with an average of only 1.89 inmates transported per run.
o Prisoner malaise towards healthcare provided can throw a wrench in medical transportation operations and be costly. When prisoners decide last minute not to go to the MMC, appointments need to be rescheduled requiring additional transport at a later date.
o Inefficient administrative practices often result in medical records not reaching the MMC for the appointment, requiring it to be rescheduled and additional transport needed at a later date.
o Costs of Vehicle Operation (1991): $201,994

2. Public Safety Concerns and Security Issues

o Possible attempts to escape require extra correctional service officers (CSOs) to attend to the transportation of inmates to MMC at a ratio of nearly two to one and guard them in a public setting.
o The Florence correctional complex houses moderate, medium and maximum security inmates, each with their own security protocols that must be followed making medical transportation and security at the hospital very complex. Maximum-security prisoners made up 51% of the prisoners transported to MMC in 1991.
o CSO’s often work more than the eight-hour shift waiting for each appointment and treatment to finish. Overtime Pay for medical transport CSOs is costly (1991): $1,730,384

3. Providing Quality Health Care to Inmates required by Law

o A federal court ruled that inmate health services are a constitutional right. Inmates are the only members of American society with this constitutional right to health care. Costello v. Wainwright 430 U.S. 325, 51 L.Ed. 2nd 372, 97SCt. 1191 (1977), 506, led to 21 years of litigation against the Florida Department of Corrections and court oversight of inmate health services.

Overall, medical transportation costs for the Fiscal Year of 1991 totaled an estimated $1,932,378. These costs will only continue to rise and security will become more of a risk as prison populations increase at correctional facilities across the nation if action is not taken now.

ADC is required by federal law to provide health care to inmates. It is important to remember that cutting medical care to save costs is not an option. Rather, cost-effective improvements need to be made to the medical care system to improve administrative efficiency, preserve quality of treatment, and reduce security risks. Providing quality healthcare to inmates is a matter of public safety as well. Because of the high number of communicable diseases that can affect prison populations, the health and well-being of surrounding communities could be severely harmed if prisoners do not receive proper health care prior to release.

SOLUTIONS

This report will discuss several possible solutions that could cut down costs from $1,932,378 in 1991 to a more reasonable amount allowable within the constraints of recent budget cuts. These solutions can be taken in phases or in particular combinations to result in a cost-effective balance between on-site resources and off-site care. In addition, these solutions directly or indirectly address all or part of the aforementioned constraints that the Florence correctional facility currently faces.

A. Improve the medical facilities at Florence
B. Utilize work-training programs to cut costs
C. Hold monthly clinics for non-emergency treatments at the prison
D. Take advantage of recent advances in electronic medical record systems
E. Telemedicine
F. Adopt preventive health care programs

Some of these solutions are more viable and cost-effective than others. Two possible solutions that are not recommended, but have been attempted in other prison facilities around the United Sates are:

G. Contract outside medical care
H. Inmate Co-Payment/ Fee for Service

A. Improve the medical facilities of Florence Prison

The main reason that the ADC has been required to allocate so much money towards the transportation of prisoners is that the medical center at the Florence Prison complex is not adequate. It would seem that many prisoners require surgeries, specialized treatments such as MRI scans and other such treatments that can only be received at a fully equipped medical center.

However, data provided by the ADC reveals that inmates are often treated for non-emergency care at special clinics at the MMC. Three of the five most common clinics used are bolded:

Orthopedics 33%
Detention Ward 28%
X-Ray 7%
Admissions 5%
Eye 5%

It is apparent from this data that by improving the medical center at Florence, even at a very minimum extent within budget constraints, security risks and costs associated with medical transportation off-site could be greatly reduced.

By simply providing basic orthopedics services, an x-ray facility and eye clinics, the number of inmates transported off-site to the MMC for medical care would be reduced by 45%. If these services had been available on-site in 1991, the number of inmates needing transportation would have been reduced from 4,950 to 2,227. The number of CSO’s delegated to medical transportation duty for non-emergency treatments of inmates would be reduced as well. Fewer CSO’s would need overtime for the transportation duties that often last longer than their normal eight-hour shift. All in all, by improving the medical center minimally, the ADC could cut the costs of medical transportation almost in half while reducing security risks.

Security risks could be further reduced, not only by transporting fewer inmates off-site to the MMC, but also on-site at the improved medical center. Improvements of the medical facility should keep security at the forefront, even if prisoners are not given full privacy. For example, by designing exam rooms with one exit, unlike the MMC exam rooms which have 2 exits, security would be greatly improved requiring less CSO’s in the medical center.

Further cost-analysis can be conducted to determine the exact costs of either improving or constructing new medical facilities at Florence. To give an idea of what the costs might be for construction of a small but modern medical facility with more amenities to serve on-site, I would like to cite a particular construction project that has recently taken place in Florida. At the Hernando Jail, a small medical center that is 4,500 square feet was constructed for $1.5 million (Tampa Bay Times, 2012). The cost is less than that spent on medical transportation by the Florence prison.

If it is cost-effective, a detention ward may be possible at the improved medical facility, but that would require heavy security and a trained staff of several nurses, as well as doctors nearby for any emergencies. This unfortunately is probably not a viable option for the current proposal. Perhaps in the future, it can be included to further reduce the number of prisoners needing transportation.

Improvement to the medical facilities at Florence should be taken in phases to reduce the costs of construction while continuing to transport prisoners off-site to MMC before construction is complete.

To assist with the costs of improvement, the ADC should seek out grant funding. For example, the Hampden County correctional facility in Ludlow, Massachusetts, was one of 10 nationwide winners of the Innovations in American Government grant program funded by the Ford Foundation. Since 1986, when the Innovations Program began, a total of $15.9 million has been granted to correctional healthcare programs that show exemplary improvement to the care of inmates (Public Health Model, 2002).

Several other solutions mentioned below, when combined with the improvements of the medical center, could further reduce the costs of the improvements as well as medical transportation. The improvement of the medical center on-site should be viewed as a necessary step in the overall process of reducing the costs of medical transportation off-site, especially as prison populations increase.

This solution addresses all of the aforementioned constraints that need to be improved while cutting costs, including the inadequate medical center currently in use, public safety and security concerns, and providing inmates with adequate healthcare required by law.

B. Utilize work-training programs to cut costs

To cut costs further, work-training programs should be utilized in the construction of the improved medical center as well as to assist with the medical care provided by the institution. Work-training programs for inmates have long been used to teach inmates particular trades, keeping idle hands busy, while providing the prison with a free source of labor.

Florence houses minimum, medium, and maximum-security prisoners. From the minimum and medium-security prisoners, Florence prison has ample inmates to select from according to security risks for construction jobs during the improvement of the medical center.

Additionally, when the medical center improvements are completed, work-training programs should be developed for inmates to help with healthcare and administrative duties. Prisoners could learn EMT skills, basic nursing, medical record data input, and much more. By assisting staff with clinics and non-emergency medical procedures, the costs of paying additional employees would be cut and provide prisoners with rehabilitation possibilities and skills to use when released.

Some may view the presence of prisoners on a medical work/training program as a risk due to the presence of drugs, needles, and other instruments of the trade. However, options are available for new drug delivery systems that are needle-free (PharmaJet, 2011). Security would also be maintained by keeping prisoner assistants in restricted areas with zero-access to drugs, needles, scalpels and the like.

This medical work-training program is not unprecedented. In the state of Oregon in 1994, voters enacted Measure 17. The measure requires correctional institutions to actively engage inmates in full-time work or on-the-job training, including prison medical services. The measure reads that:

Inmate work shall be used as much as possible to help operate the corrections institutions themselves, to support other government operations and to support community charitable organizations. This work includes, but is not limited to…prison medical services… Every state agency shall cooperate with the corrections director in establishing inmate work programs (Oregon Constitution, 1994).

As with other work-training programs, Oregon’s inmates are exempt from the program if participating presents a health or security risk. Of the work eligible prisoners, some are not compliant. However, as recently as August 2012, 67% of Oregon’s total prison population (14,299 inmates) was compliant and active in the work/training programs (Department of Corrections, 2012).

This solution may also have the added benefit of improving prisoner malaise towards the healthcare provided at Florence prison. Learning is power, and with the added knowledge of the body, diseases, treatments, EMT procedures, and more, inmates may take more of an interest in their own health as well as the health of others.

C. Hold monthly clinics for non-emergency exams at the prison.

A third solution to cutting costs of the medical transport of inmates offsite to Maricopa Medical Center is to use the current medical facilities at Florence prison to hold monthly clinics for non-emergency exams. This could be done before, during and after the improvements to the medical facility are being made.

Non-emergency clinics have the benefit of keeping inmates on-site rather than transporting them offsite for vision appointments, health screenings, and more. The vision clinic alone would keep 5% of inmates onsite. In addition, the costs would not necessarily increase because there would not need to be salaries for permanent staff.

Clinic staff would consist of nurses and doctors who travel to the prison when the clinics are scheduled. If an inmate skips the clinic, it is not as detrimental as skipping an appointment because it is non-emergency and the clinic will be back the following month. In contrast, when prisoners skip appointments at the Maricopa Medical Center, it is very costly for the prison. Medical transportation that has already been scheduled is no longer full, which is the most cost-effective way to transport prisoners at once. Two different medical transport runs each carrying only one or two inmates is much more costly than one transport carrying four. When inmates skip an appointment it must be rescheduled and additional transportation costs incurred at a later date.

Holding clinics on site in the current medical facilities naturally keeps the costs and security risks down compared to transportation off-site. Fewer prisoners would be in the halls of the Maricopa Medical Center, making medical staff and patients of the public nervous. Whatever small costs a monthly clinic may incur for the prison, it is much less than the costs of transportation and security to Maricopa Medical Center.

Many doctors and nurses volunteer their time at clinics, giving back to the community. It is possible to make arrangements with the monthly clinic staff to make the monthly clinics a form of community service for them, decreasing costs even more.

As improvements to the current medical center continue to expand the types of medical services that could be provided, additional monthly clinics could be scheduled for other treatments.

D. Invest in Electronic Medical Records

Another cost-effective improvement that could be made in combination with these other solutions is investing in an electronic medical records system. The electronic medical records system would benefit both the medical center at Florence prison as well as the Maricopa Medical Center.

According to the study, “A cost-benefit analysis of Electronic Medical Records in primary care,” the estimated net benefit of using an electronic medical record system for a 5-year period was $86,400 per provider. The savings primarily were the result of savings in drug expenditures, improved radiology tests, better capture of charges and decreased billing errors (Wang, 2003). Additional savings would be made by the prison and Maricopa Medical Center with regards to medical transportation costs if the prison invests in electronic medical records.

According to the data presented by the ADC, 5% of prisoners spend most of their time at admissions when they are at the Maricopa Medical Center. With every visit, new forms may need to be filled out. However, an electronic medical records system at the Florence prison would allow for particular medical charts to be easily synced up with the electronic medical record system of the Maricopa Medical Center.

ADC cites that one of the reasons that inmate appointments are cancelled and rescheduled is due to charts not making it to the Maricopa Medical Center. Rather than quickly gathering paper charts for inmates on the day of the appointments and giving them to the medical transport staff, notes can be made of which inmates are on the transport and which inmates skipped. The files can be transferred electronically to the Maricopa Medical Center in the 75 minutes it takes the transport to reach the hospital. If an inmate’s record is still missing from the batch sent over, the Maricopa Medical Center need only to make a phone call requesting that chart, which can be there within minutes.

Electronic Medical Record systems are an investment, but a cost-effective one. The medical information can be electronically tied in with the prison’s electronic manifests, keeping an inmate’s information all together in one place and requiring less administrative work on behalf of permanent staff. Electronic Medical Record systems could also easily eliminate the need for appointments to be rescheduled due to missing patient information. When appointments are cancelled, transportation costs are incurred for additional trips at later dates.

Security risks would also be reduced when prisoners are at the Maricopa County Medical center because they would spend less time at admissions as well. The electronic medical record technology allows for a faster, more efficient admissions process. Security risks would be decreased if prisoners can be transferred more quickly from admissions to their appointment, getting them away from the members of the general public that are also checking in at the hospital.

E. Telemedicine

Using telemedicine is another way to lower the costs of prisoner transport to Maricopa Medical Center. Telemedicine is loosely defined as “the remote delivery of health care via telecommunications” (Telemedicine, 1999). Using telemedicine in prisons provides a viable means of addressing the issues of cost and access to specialists. As the prison population ages, inmates need more medical care than the basic clinics that are provided in an updated medical center and free clinics. Telemedicine provides inmates with any necessary specialist care without the costs or security risks of transportation off-site to see specialists or the costs of an expensive visit to the prison by the specialist.

In the 1990’s, an escape attempt by an inmate in Lewisburg, Pennsylvania, during a trip to the local hospital that resulted in the death of a security guard peaked the Federal Bureau of Prisons interest in using telemedicine as a means of delivering health care to prisoners with low cost and low security risk (Telemedicine, 1999). As technology has improved, the costs have become even lower while the number of consultations, and thus the quality of health care provided to inmates, has increased.

An evaluation by the Department of Justice of telemedicine use in prisons revealed that it was widely embraced by prisoners and officials (Telemedicine, 1999). During the yearlong evaluation 84% of all teleconsultations were with psychiatry, dermatology, orthopedics, and cardiology specialists. The evaluation also found that telemedicine reduced the number of external visits to specialists, as one would expect. A small prison in comparison to Florence, Lewisburg had transported prisoners to offsite medical centers 419 times in the year prior to telemedicine being introduced. With telemedicine, 35 trips were averted the following year, saving the prison approximately $27,500 (Telemedicine, 1999). These savings, when applied to the almost 5,000 trips offsite that Florence undertook in 1991, would have been astronomical.

The costs of setting up telemedicine communications devices in 1999 required a room with a camera, a patient camera, monitor, video conferencing software ($64,500 each), digital stethoscope ($3,225) and an intraoral camera ($5,375) (Telemedicine, 1999). However, as of 2012 technology has improved immensely and with that the costs will inevitably be even lower. For example, real-time video conferencing is common and free using Skype with a simple laptop camera. The use of electronic medical records means that specialists can immediately review charts from hundreds of miles away without the need to fax or send copies via mail prior to appointments. Even with the costs of equipment in 1999, the evaluation found that only 1,544 encounters via teleconsultations would save an amount equal to the purchase of that equipment (Telemedicine, 1999). Even though 1,544 consultations seems like a high number, by the end of the yearlong demonstration, 1,321 teleconsultations had taken place, meaning the return on the investment would take only two years at the most.

Other benefits of telemedicine besides saving the prison money are the fewer security risks for transfers and external consultations, shorter waiting times to see specialists, and access to better quality specialists not previously available. Specifically, the Department of Justice also found that with telemedicine, there were fewer acts of aggression by inmates, or use of force by guards, due to improved mental health services and fewer grievances from prisoners about health care or mental health care (Telemedicine, 1999). With these benefits of telemedicine noted by the evaluation, programs are in place now within the Bureau of Prisons to assist prisons with the set up and implementation of telemedicine systems.

Telemedicine systems at the Florence prison complex would greatly reduce the number of offsite medical transports needed by inmates, reducing the costs for the prison immensely and reducing security risks associated with the transports. While being cost-effective, telemedicine improves the health care provided to prisoners rather than prisons resorting to cutting care to cut costs.

F. Preventive Healthcare programs should be adopted.

Preventive healthcare has been a rising trend in all areas of medical care in the U.S. As medical care costs rise for every citizen and insurance companies continue to be selective with who is eligible for health insurance, the importance of being healthy and maintaining that health has become the forefront of American health care. Prisons should be no exception and should attempt to educate inmates through preventive health programs, even if we ask ourselves whether or not “healthy prisons” is a contradiction in terms due to the inherently non-therapeutic environment of prisons (Smith, 2002).

In an effort to reduce costs of medical care and security risks of numerous medical transportation trips off-site to the Maricopa Medical Center, Florence prison should begin to implement proactive preventive health programs. An additional reason preventive health program should be enacted is the importance of ensuring prisoners who are released do not pose a health threat to their community.

Several reasons exist for why the health care costs of prisoners is on the rise, one of which is an expanding prison population composed of inmates whose lifestyles prior to and during their terms of incarceration make them one of the unhealthiest populations in the nation. These lifestyle habits result in a much higher percentage of infectious/communicable diseases and chronic diseases in the prison population when compared to the population of the U.S.

Infectious and communicable diseases are those diseases that can be spread within prisons as well as to the surrounding communities if inmates are uneducated through preventive health programs. This category includes sexually transmitted diseases (syphilis, gonorrhea, chlamydia), hepatitis B, hepatitis C, HIV, AIDS, and Tuberculosis. According to the National Commission on Correctional Health Care, in 1997 it was estimated that at least 200,000 inmates had some form of STD (Trends Alert, 2004). This number has surely increased as populations rise in prisons.

Other cases communicable diseases spreading have occurred in the past. In 1991, the Rikers Island Jail had one of the highest TB rates in the Nation and in LA, an outbreak of meningitis spread to the surrounding neighborhoods from the county jail. Without proper education regarding ways to control the spread of these diseases, health care costs dramatically increases for the prison system as treatment needs increase (Prisoner Reentry, 2001). Preventive health programs have shown huge decreases in the number of afflicted inmates as well savings in health care costs due to the need for fewer treatments.

Part of preventive health programs is disease screenings for multiple communicable and chronic diseases upon intake that are followed up with care when needed and prevention education for all. The Texas Correctional facility initiated a program utilizing trained and approved offenders, saving money from hiring outside educators, to instruct other offenders in health prevention topics of all major infectious diseases and the preliminary evaluations are promising, showing a decrease in at risk health behavior (Trends Alert, 2004). Additional preventive education can occur regarding sanitary conditions with programs to train inmates in preventative health care including basic sanitation, food preparation and personal hygiene.

With preventive health are programs in place, fewer trips will be needed to outside facilities if prisoners are taking care of themselves in a preventative manner before health failures begin, saving the prison money and reducing security risks of off-site transportation. The Federal Bureau of Prisons publishes a clinical practice guide for preventive health care in correctional facilities to keep all screening and education up to date for prisoners at every age, gender, and health risk.

POSSIBLE SOLUTIONS THAT ARE NOT RECOMMENDED

The high costs of medical care for inmates has been approached by state prison systems in a number of different forms in an attempt to lower those costs, reduce security risks, limit off-site transportation, and more. Some of these possible solutions have not worked as well as the solutions mentioned above and are therefore presented here, but not recommended as the best possible solution.

G. Contract outside medical care providers.

Contracting outside medical care providers is a separate option from the previously mentioned solutions. All costs incurred by the current medical care system at the Florence prison would be redirected towards a contract with a specialized correctional medical service provider. These costs may seem worth it at the time for the quality and diversity of services rendered. However, over the long run, it may be more expensive to contract medical care providers than to improve upon the medical care system already in place.

In 2010, the Legislative Analyst Office of California’s state government researched the healthcare costs incurred by the California prison system for health care to inmates. What the LAO found was the following:

The increase in correctional health care costs has been largely driven by greater usage of contract medical services, such as for specialty medical care provided outside prison, private ambulance transportation, and nursing and pharmacy registries. In recent years, contract medical costs have more than doubled — increasing from $394 million in 2005–06 to $845 million in 2008–09 (LAO, 2010).

California is a much larger state than Arizona, housing nearly 171,000 inmates in 2007 (LAO, 2007). However, the analysis shows that medical care costs are increasing and contracting medical care providers is not necessarily a cost-effective solution for any prison system. As costs increase for the contracted care providers, they do not have incentives to find ways to cut those costs while still providing quality health care. Rather, they raise the annual fee leaving prison’s responsible for incurring the costs with no way to find cost-saving methods due to the contract with the medical care provider. Or the contracted medical provider begins to offer substandard health care to inmates with little transparency due to a lack of government oversight in the private medical system, as will be discussed below.

Services provided by contracted correctional medical care providers are wide reaching in scope. One such contract correctional medical care provider’s services to inmates includes “reception screening, physician services, specialty clinics, mental health services, nursing care, comprehensive dental care, infirmary care, pharmacy care, comprehensive hospital care, laboratory services, medical records management, electronic medical records, utilization review, quality improvement, and medical education” (http://www.cormedcare.net/services.html). With one contract, a prison can put almost all of the challenges of providing health care to inmates into the hands of these correctional medical care providers, including medical administration responsibilities. It is a simple solution, yet, as mentioned above, the costs may not be worth the simplicity.

Transportation of inmates off-site to Maricopa Medical Center is still a possibility for many of the inmates seeking services of the contracted medical care providers. Contracted correctional medical care providers realize the costs and security risks of these transportations. One contract provider, Correctional Medical Care, says on their website that their philosophy is to “utilize on-site service wherever possible to mitigate security risk and reduce your costs associated with transportation and correctional officer overtime” (http://www.cormedcare.net/services.html). Even so, the on-site facilities at Florence Prison may not be adequate without the recommended improvements to avoid off-site transportation.

Recently, Arizona Representative John Kavanagh argued in favor of privatization of the prison health care as a way to save money for the state. Even though the ADC’s $349 million three-year contract with Wexford Health Sources Inc will cost the state an additional $5 million on health care for its 34,000 prisoners as of 2011, Kavanagh argues that the state will save money in the long run from reduced pension costs by eliminating hundreds of state employees through the privatization (The Republic, 2012). This is typical of government, rationalizing additional spending in one sector while cutting jobs and pensions in another, while not necessarily improve the health care for inmates in a cost-effective manner.

Wexford has had its share of challenges in other state correctional facilities that outline some of the precautions that should be taken when privatizing the prison health care system. Government run prison health care systems are constantly reviewed and monitored to ensure certain standards of care are being met in a cost-effective way. Wexford and the operations of other private medical care providers are not easily transparent to ensure quality care is being given.

For example, New Mexico terminated their statewide contract with Wexford in 2007 after an audit by the state finance committee found shortages of physicians, dentists and other prison medical staff and noted that Wexford failed to issue timely reports on the deaths of 14 inmates the previous year (The Republic, 2012). If not for the financial audit, Wexford would have continued operating their correctional care at substandard levels. Wexford’s contract was also terminated with a county jail in Washington after complaints that medication was not being dispensed to inmates in a timely fashion, resulting in psychological and behavioral problems with inmates on psychotropic drugs creating a dangerous environment for fellow inmates and prison guards (The Republic, 2012). Wexford is not the only privatization of correctional medical care to present issues to states.

Florida attempted to use privatization to control the costs of inmate health care with mixed results. Once again, Wexford was contracted as the source for comprehensive health care to inmates in South Florida prisons and were repeatedly found to be noncompliant with contract requirements for services provided (OPPAGA Report, 2009). The department re-bid the contract in 2005, granting it to Prison Health Services, another privatized correctional medical care provider. But, in 2006 when Prison Health Services had higher than expected rates of hospitalization resulting in higher costs, they attempted to request additional compensation, putting the burden of higher costs on the prison system rather than seeking to ways in which to cut costs while providing quality services (OPPAGA Report, 2009). Private correctional medical care providers are meant to be profit generators, unlike government run prison systems that work within tight budget constraints. The fact that Wexford and Prison Health Services desire to generate profit puts that at the forefront of their business model rather than the health care of inmates.

Due to the security risks, substandard health care possibilities and the added costs, privatization of the prison health care system through contracts with correctional medical care providers is a solution, but not nearly the most desirable. Contracting outside medical care, however, may be still be viewed as an option on a trial basis or for during a transitional phase as the current medical care system at Florence Prison is updated with Electronic Medical Records, Telemedicine, expanded facilities, monthly clinics and more. It certainly requires more research and moral consideration.

H. Inmate Co-Payment/ Fee for Services

As of 2005, all U.S. Federal Prisons and about 70% of state prisons have copayment schemes for inmate health care (Awofeso, 2005). The idea behind inmate co-payment programs for health care services is twofold. First, the money helps to offset medical expenses incurred by the prison. Secondly, the co-payment program aims to reduce unnecessary sick call visits, including off-site transportation to public medical centers, lessening the strain on medical services. The passing of the Federal Prisoner Health Care Copayment Act of 2000, which requires fees for services of no less than $1 with part of the proceeds paid into the Victims of Crime fund, solidified the use of co-payment programs in all U.S. Federal Prisons (Public Law 106–294, 2000). The aims of the co-payment programs seem positive and beneficial to the prison system to reduce costs of care as well as the costs of unnecessary transport to off site medical centers. However, the prisoners do not benefit from the program and providing quality health care to them is a constitutional right that must be upheld.

While reducing health care costs at prisons, inmate copayment policy has had an adverse affect on the health care available to inmates, particularly the poor, chronically ill and elderly prisoners. A $5 sick call fee is equivalent to two day’s of wages so the chronically ill and elderly prisoners who are physically unable to work yet have greater health needs have the least income and suffer from copayment policies (Awofeso, 2005). When an inmate’s commissary or trust fund, often maintained while incarcerated, is no longer able to be sustained, inmates may not be able pay for all of the health care services needed, even with small fees just over $1.

It is important to note that if inmates cannot pay, they cannot be denied health care services due to their constitutional right. However, many inmates view co-payment plans and fee-for-care services as illegal and numerous lawsuits have been filed challenging these programs. This may not be costly for the prison system, however the lawsuits are costly for the state.

CONCLUSION

In this comprehensive report, several solutions are discussed for cutting down costs incurred by the Florence prison complex due to the medical transport of inmates off-site to Maricopa Medical Center. Costs are incurred from expensive appointments, transportation, and security, particularly overtime pay for CSO’s monitoring prisoners at the public health facility for over eight hours including 75 drive to and from Florence. The report also covers two potential solutions utilized in other prison systems that are not highly recommended for application at Florence.

In 1991, the total cost of medical transportation of inmates off-site to Maricopa Medical center was $1,932,378. As prison population rates have increased, so have the costs of health care. Health care costs have further increased due to higher numbers of communicable and chronic disease needing treatment within prisons and an aging prison population that requires more care as time goes on. Solutions to keep high standards of health care while cutting costs and reducing the need for medical transportation to off-site facilities, as well as reducing the costs and security risks associated with medical transportation off-site include:

A. Improve the medical facilities at Florence

o This solution is highly recommended. As prison populations increase, the costs of additional medical transportation off-site will increase with it unless adequate facilities are available on-site.

B. Utilize work-training programs to cut costs

o Inmates can be utilized for the construction/improvements to the medical facilities. Inmates can also be trained to assist with medical services including administration, nursing, EMT, and preventive health education programs.

C. Hold monthly clinics for non-emergency treatments at the prison

o Three clinics at the Maricopa Medical Center account for 45% of the medical transports off-site: Orthopedics, X-ray, and Vision. These clinics and others could be offered to prisoners on-site when the improvements have been made to the medical facility at Florence, if not before, with the acquisition of some basic medical equipment that would be very cost-effective when compared to the costs and security risks of transporting prisoners off-site.

D. Take advantage of recent advances in electronic medical record systems

o Electronic medical record systems would reduce the number of cancelled and rescheduled appointments and transportation to the Maricopa Medical Center due to patient charts not making it to the center, a common occurrence. It would also greatly reduce time inmates spend at admissions and allow for accurate medical histories of treatment to be stored for easy transfer to other institutions or via telemedicine.

E. Telemedicine

o Telemedicine has become a widely used method of providing quality care to inmates from specialists around the country while keeping them on-site. As technology advances, video-conferencing software and hardware has become cheaper and cheaper. It is so successful at saving prisons money and making inmates feel that they are receiving adequate care that the number of prisons utilizing telemedicine and the number of inmates participating in teleconsultations with a wide range of specialists as dramatically increased over the years. Prisoners no longer need transportation to specialists off-site, saving the prison system a lot of money and preserving public safety.

F. Adopt preventive health care programs

o Preventive health care programs screen for and educate inmates about chronic and communicable diseases as well as ways in which to live healthier lifestyles in prison and after release. Protecting surrounding communities from communicable diseases is very important for the health care systems of the prison and should be taken very seriously. Preventive health programs also have been shown to successfully reduce spread of diseases that require increased treatment and incur increased costs.

The two possible solutions that have been used elsewhere but are not recommended are:

G. Contract outside medical care

o Privatization is expensive due to contract medical care requiring profits. As costs increase, contract medical care companies have little incentive to work within budget constraints and instead pass the increasing costs off to the prisons by increasing contract fees. Additionally, unlike government run and regulated prison systems, the contract medical care companies are often able to provide inmates with inadequate care for a while before anyone takes action to contract out to another firm or find alternative solutions.

H. Inmate Co-Payment/ Fee for Service

o While the motivations behind inmate co-payment seems positive for the prison system, by helping with costs and reducing unnecessary medical appointments, it is not positive for prisoners who cannot afford the couple of dollars needed for co-pay, particularly the poor, chronically ill, and elderly. Inmates are still required to receive treatment even if they cannot pay, however, the legality is questionable and lawsuits are expensive for the state.

In conclusion, the ADC and Florence prison should begin considering which of the aforementioned recommended solutions they would like to phase in, in part or in full.

These solutions should be taken in phases or in particular combinations to result in a cost-effective balance between on-site resources and off-site care while preserving the health care of inmates required by law. In addition, these solutions directly or indirectly address all or part of the constraints that the Florence correctional facility currently faces, including the inadequate on-site medical facility at Florence, budget cuts, and security risks.

References

McDonald, Douglas C. Medical Care in Prisons. Journal of Crime & Justice, 1999: 26; 427.

Marrero, T. “Hernando Jail’s Medical Facility is getting an Upgrade”. Tampa Bay Times; July 14, 2012. Retrieved from http://www.tampabay.com/news/localgovernment/hernando-jails-medical-facility-is-getting-an-upgrade/1240216

Sheriff Michael J. Ashe, Jr. “A public Health Model for Correctional Health Care: A Guide for Correctional Facilities to put Public Health Services into Practice”. Hampden County Sheriff’s Department; Ludlow, MA. October, 2002.

PharmaJet. Needle Free Injection System. 2011. Retrieved from www.pharmajet.com

Oregon Constitution, Section 41, Measure 17: Inmate Work Act.1994. Retrieved from http://www.oregon.gov/DOC/RESRCH/pages/measure_17.aspx

Oregon Department of Corrections. Measure 17 Compliance Source Data. 2012. Retrieved from http://www.oregon.gov/DOC/RESRCH/docs/m17source.pdf

Wang, S.J., MD, et al. A Cost-Benefit Analysis of Electronic Medical Records in Primary Care. American Journal of Medicine 2003; 114: 397–403.

Telemedicine can reduce correctional health care costs: An evaluation of a prison telemedicine network. National Institute of Justice, NCJ 175040: March 1999.

Overview of Adult Correctional Health Care Spending. Legislative Analyst’s Office, California. March 18, 2010.

How Many Prison inmates are there in California?: 1987 through 2007. Legislative Analyst’s Office, California. 2007. Retrieved from http://www.lao.ca.gov/laoapp/laomenus/sections/crim_justice/5_cj_inmates.aspx?catid=3

Ortega, Bob. Arizona prison’s health care to be run by Pa. company. The Republic, AZcentral.com. April 3, 2012. Retrieved from http://www.azcentral.com/news/articles/2012/04/03/20120403arizona-prisons-health-care-run-by-penn-company.html

Costello v. Wainwright 430 U.S. 325, 51 L.Ed. 2nd 372, 97SCt. 1191 (1977), 506

Steps to Control Prison Inmate Health Care Costs have Begun to Show Savings. OPPAGA, Report no. 07–09. January 2009.

United States 106th Congress, 2000. Federal prisoner health care co-payment Act of 2000. Washington, Public Law 106–294, 12 October 2000.

Awofeso, Niyi. Making Prison Healthcare more Efficient: Inmates need more organized and more preventative health care in emptier prisons. BMJ 2005; 331: 248–249.

Hillestad, R., et al. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings and Costs. Health Affairs, 24, no.5 (2005): 1103- 1117.

Smith, Catrin. ‘Health Prisons’: A Contradiction in Terms? The Howard Journal of Criminal Justice, 2002. 34; 4: 339–353.

Thorburn KM. Health Care in Correctional Facilities. West J Med, 1995; 163: 560–564.

Kinsella, Chad. Corrections Health Care Costs. The Council of State Government Trends Alert, 2004.

Petersilia, J. Prisoner Reentry: Public Safety and Reintegration Challenges. The Prison Journal, 2001; 81, no. 3: 360–375.

Preventive Health Care. Federal Bureau of Prisons, Clinical Practice Guidelines. July, 2011.

Photo by Grant Durr on Unsplash