Abstract
More than half of the state prisons in the United States outsource health care. While most states contract with private companies, a small number of states have reached out to their health science universities to meet their needs for health care of prisoners. New Jersey is the most recent state to form such an agreement. This article discusses the benefits of such a model for New Jersey’s Department of Corrections and for New Jersey’s health sciences university, the Rutgers University, formerly the University of Medicine and Dentistry of New Jersey. The benefits for both institutions should encourage other states to participate in such affiliations.
Introduction
More than half of this country’s prisons have outsourced health care in efforts to reduce medical costs and improve quality. Most states have turned to private companies. In a partial reversal of this trend, a few states have sought these services through their states’ health sciences universities. These have included Texas, Connecticut, Georgia, Louisiana, New Hampshire, and Massachusetts. New Jersey recently joined the ranks of this select group of states by contracting its health science university—the Rutgers University (RU)—to provide health care to inmates under the auspices of the New Jersey Department of Corrections (NJDOC).
In 1999, pursuant to class action litigation in federal court, the NJDOC entered into a settlement agreement with its inmates to comprehensively improve the mental health care provided to inmates (D.M. et al. v. Jack Terhune et al. (1999)). After several years, and despite generous funding that supported this agreement, the private, for-profit health care company contracted by the NJDOC to provide mental health care to New Jersey’s inmates could not meet the rigorous terms of the agreement. In 2005, the NJDOC terminated its contract with the private provider and formed an agreement with the University of Medicine and Dentistry of New Jersey (UMDNJ) to provide mental health services. This led to the formation of University Correctional HealthCare (UCHC) within UMDNJ. UCHC delivered all required services, and all criteria were met for male inmates within 2 years of the NJDOC/UMDNJ partnership. In October 2008, NJDOC expanded the agreement to have UMDNJ provide all health care services. In July, 2013, UMDNJ merged with RU. The partnership between both NJDOC and RU has benefited both institutions. Benefits to NJDOC include improved quality of care and cost savings. The combination of these benefits, in turn, may have reduced the risk of litigation. Benefits to RU include fulfillment of its public health mission, training of health care professionals, and research in the health care of inmates.
Benefits to the NJDOC
Quality Health Care to Inmates
Outcomes
A high quality of care is one half, and the most important part, of a successful correctional health care operation. (The other half is the cost of the services.) UCHC is currently providing a level of mental health and medical services to inmates in the prison system that is achieving better outcomes than what is typically found in the community:
For hyperlipidemia, UCHC achieved low-density lipoprotein levels equal to or less than 130 in 69% of patients in 2011.
For hypertension, 89% of patients with hypertension were below the 140/90 threshold in calendar year (CY) 2011. This figure bests the Michigan Department of Corrections’ (MDOC) 65.3%, commercial insurers’ 62.2%, Medicare’s 57.7%, and Medicaid’s 53.4% (Quality Assurance Office of the MDOC, 2009).
For diabetic care, 59% of inmates achieved hemoglobin a1c (Hgba1c) less than 7 in the second half of CY 2011. This compares favorably with the MDOC, whose similar figure was 48.4% (Quality Assurance Office of the MDOC, 2009).
For HIV-infected inmates, the percentage with CD4 counts below 200 has decreased from an average of 12.5% in CY 2009 to 9.4% in CY 2011 and 6.9% in CY12. The decrease is an indication that an increasing number of our HIV patients are at low risk for opportunistic infections. According to the Centers for Disease Control and Prevention (2011), 58% of HIV-positive individuals in the United States had CD4 counts < 200. Furthermore, 85% of UCHC’s HIV-infected patients who have been receiving treatment for at least 6 months are obtaining undetectable viral loads of < 70 copies/ml. As a quality benchmark, the Yale School of Medicine (Springer et al., 2004) documented that 59% of their HIV patients on HIV medications at the time of discharge from a Connecticut prison achieved virological suppression of a viral load < 400 copies/ml.
Inmates have also enjoyed improved mental health care. NJDOC provides a continuum of psychiatric services (especially prison inpatient units) according to a model outlined by Patterson and Greifinger (2007) and incorporated into the CF v. Terhune Settlement Agreement (D.M., 1999). About 10% (300) of the inmates with mental health needs require placement in these inpatient units at any point in time. The remainder receives services comparable to outpatient services in the community. All inmates receive a discharge plan and psychiatric medications upon release.
With enhanced psychiatric services, discharge planning, and cooperation with the state forensic hospital, which helps UCHC find discharge options for patients, fewer inmates are committed to the state’s forensic hospital. Since UCHC assumed responsibility for mental health services in 2005, transfers to New Jersey’s state forensic psychiatric hospital dropped by about 80% (123 to 25 annually). This reduction has taken place without an increase in the suicide rate. In other words, NJDOC and UCHC are taking care of their own, and their patients are not suffering for it.
Quality/performance improvement
While continuous quality improvement/performance improvement (PI) is a requirement for maintaining accreditation through the National Commission on Correctional Health Care (NCCHC), it is also a critical practice for any health care program striving for excellence. UCHC has raised awareness of and participation in PI through the collaboration of multidisciplinary PI teams. Teams from every prison participate in an annual PI fair. UCHC has made PI an ongoing part of its service delivery (Raab, DeBilio, & Ausfahl, 2007). Successful projects at individual prisons have been disseminated statewide. For example, a successful project to lower Hgba1c in diabetic patients was used to improve these results statewide. Indeed, in its 2010 accreditation survey of NJDOC, NCCHC commended UCHC on the uniqueness and benefit of UCHC’s PI fair.
Staff recruitment, retention, and training
A stable health care staff presumably contributes to the health of patients. However, recruitment and retention are challenges in correctional settings. Health care professionals may perceive the prison environment as harsh, oppressive, and intimidating. NJDOC has benefited from UCHC’s successful recruitment and retention of health care professionals (800 full-time equivalent positions filled by approximately 1,100 individuals) despite the unique challenges. The vacancy rate quickly dropped well below 10% at all prison sites. Since 2005, the turnover rate for UCHC staff has mirrored the approximate 10% to 13% annual rate of RU’s University Behavioral HealthCare (UBHC), the parent organization of UCHC. The reasons UCHC has managed to provide adequate and stable staffing are speculative, but probably involve the reasonable caseloads, minimal managed care-type restrictions, excellent employment benefits such as tuition reimbursement, and competitive salaries.
Through partnering with RU, health care staff now benefit from an array of training in various evidence-based practices. The medical school partnership helps to ensure high-quality diagnostic and treatment services via the creation and implementation of state-of-the-art, evidenced-based practices. Reeves (2012), UCHC’s director of psychiatry, published a peer comparison approach to reduce prescriptions of benzodiazepines and low-dose quetiapine. Treatment guidelines developed by UCHC include anticoagulation therapy, HIV therapy, schizophrenia, depression, attention-deficit/hyperactivity disorder, naltrexone for alcohol dependence, diabetes, hypertension, asthma, seizure disorder, and chronic pain.
Electronic medical record (EMR)
NJDOC uses an EMR. Specialists providing services to inmates submit their dictated medical reports through the primary care provider for inclusion in the EMR. The EMR also has a multitude of reports to facilitate the renewing of orders and the scheduling and tracking of patients and specialty referrals. This system also enables UCHC and NJDOC to monitor UCHC’s compliance with guidelines for timely access to care (e.g., initial assessments and sick call) and the documentation of this care.
Cost Savings
Structure of agreement
Unlike states with a risk-based health maintenance organization managed care model, NJDOC formed a cost-based agreement with RU, complemented by an annual not-to-exceed budget. This cost-based agreement pays a state for the cost of services, plus a small overhead for indirect costs including human resources and financial services. This differs from a risk-based or capitated agreement that pays a vendor a fixed fee, with any amount unspent by the vendor representing the vendor’s profit. The structure of the agreement between NJDOC and RU limits risk to both parties. Expenses are monitored monthly, and meetings are held between UCHC and NJDOC to address anticipated overages. This agreement requires transparent arrangements with flexibility between parties. Since forming the agreement with NJDOC, UCHC has consistently operated below the annual budget.
Staffing
The biggest budget component of correctional health care is staffing. To control costs, the NJDOC, before UCHC assumed responsibility, replaced many physicians with nurse practitioners and physician assistants. Some registered nurses (RN) had also been replaced by licensed practical nurses, nursing assistants, and medical technicians, who receive training to handle routine health care tasks under the supervision of RNs. Such changes are consistent with community standards, and UCHC reinforced these efforts with growth in educational programming for these professionals. UCHC offers, among others, trainings in medication administration, suicide prevention, chest pain evaluation, medical communication, and wound care.
UCHC has reduced overtime by monitoring schedules, establishing processes when backfilling for callouts, and offering additional hours first to part-time staff who have not worked sufficient hours to qualify for overtime pay. By establishing a system of reviewing overtime and providing site nurse managers with feedback on their utilization compared to their peers, UCHC achieved a 10% decrease in overtime in 2011.
Closing underused specialty units has had an even greater impact on staffing budgets without compromising care. Combining two underutilized mental health units and closing one infirmary produced about US$2 million savings in health care costs, and provided NJDOC with more than 90 additional beds for general population. These additional beds, in turn, saved NJDOC an additional US$2 million in operating expenses.
Controlling referrals to specialists
NJDOC and UCHC have committed to providing only necessary medical procedures and interventions based on a review of both the risks and benefits. Our primary care providers assess inmates’ actual functioning rather than merely accepting inmates’ self-reports. These assessments use collateral sources and also consider the patients’ treatment compliance history.
The UCHC outpatient utilization process for specialty care referrals includes the use of standard criteria along with a peer review component, both of which focus on the medical necessity of the referral. The peer review provides not only standardization but also collaboration and education on requests for procedures and consultations. For those referrals that are elective, the reviews focus on the functional status of the patient. In the first year of implementing these reviews, consults dropped from 554 to 439 per month.
Productivity and on-time performance
Starting in 2005, dentists have been provided with productivity feedback that is incorporated into their annual performance reviews. Dental visits, as documented in the EMR, increased from 18,628 in fiscal year (FY) 04 to 54,216 in CY10—a nearly 200% increase, while dental staffing increased by only 20%. This process has also been effectively implemented with our primary care providers. The result has been an approximately 20% increase in productivity.
The increase in productivity has resulted in greater consistency in achieving the required clinical contacts and documentation. More specifically, UCHC has seen improvements in achieving the 35 medical, mental health, and dental objective performance indicators at 97% or greater compliance levels. These are process measures to assure that inmates’ health care encounters (e.g., intakes) occur within the time frames required by the CF v. Terhune settlement agreement (D.M., 1999) and within standards for documentation as required by NCCHC.
Medical hospitalization
With a population of about 24,000 inmates, an average of only 10.2 inmates per day were hospitalized in 2011, and about 58 inmates per month required a trip to the emergency room (ER). Average hospital stays have been 4.5 days. This inpatient rate of about 1 per 2,000 inmates is half the rate recommended by NuPhysicia (2010) based on Texas’ and Georgia’s utilization rates. New Jersey’s lower rates have been achieved through close partnering with the treating hospital physician, and returning the patient to an infirmary level of care as soon as possible.
By limiting ER trips to medical situations beyond the limits of correctional facility infirmaries, UCHC reduced brief hospitalizations, thereby containing medical and custody costs. As a result, use of ERs and hospital beds is radically lower than in the community. From Kaiser’s State Health Facts, 400 per 1,000 persons in New Jersey’s population visited an ER annually (Kaiser Family Foundation, 2009a). Comparatively, only 29 inmates per 1,000 inmates visited a hospital ER annually. For hospital days, New Jersey had 639 inpatient days per 1,000 people in the general population (Kaiser Family Foundation, 2009b), while NJDOC had 155 inpatient days per 1,000 inmates. NJDOC’s hospitalization rate of inmates is one quarter and its ER use is just 7% of the general population’s rate.
Pharmaceutical cost controls
Rising prescription drug costs are a concern across the United States as well as in NJDOC. However, within the first year of operations, New Jersey saw a 12% reduction in the monthly cost of pharmaceuticals for inmates’ mental health, medical, and dental care. These savings were achieved by closely working with NJDOC and agreeing to the following: the use of generic medications within the same class, crushing generic medications instead of ordering more expensive quick-dissolving brands, using half tablets or multiple tablets to achieve a prescribed dosage when cost favorable, minimizing excessive inventory and waste, reviewing pharmaceutical pricing agreements with other public entities to assure favorable pricing from vendors, and creating a formulary that paid attention to cost while ensuring quality.
Telemedicine
Having set a goal to learn from and replicate the national award-winning telemedicine program at the University of Texas Medical Branch, UCHC has directed significant efforts toward developing telemedicine within NJDOC. The University of Texas program, which initially started within corrections, has been recognized for reducing the costs of patient care while improving patient education and wellness in both correctional and community settings (Vo, 2008).
The NJDOC-RU telemedicine system is in its early stages. Components in place include teleconferencing equipment (Polycom) in all NJDOC prisons; an EMR program (Centricity); laboratory and X-ray results transmitted into the EMR; and transmission of hospital testing results and specialty consultations into the EMR. Telemedicine has allowed patients to be served by the infectious disease specialist without the physician having to travel to the prison or the patient having to be transported to the physician. Teleconferencing has also been used to provide other specialty consults and psychiatry coverage at remote sites, and to provide staff training and consultation. Excluding infectious disease consults, telemedicine consults in 2011 averaged about 21% (121 of the 566 per month) of all specialty consults. By reducing officer and inmate transportation costs, the savings to the NJDOC is about US$100 per telemedicine consult.
Overall financial impact
Along with the improvement in the quality of care, NJDOC has realized the following financial benefits: reduced physical health services budget for FY 2012 by 12% (from US$113 to US$99 million) compared to FY 2011, and reduced mental health services budget by 27% (from US$51 to US$37 million for FY 2012) compared to CY 2006.
The continuum of health care within NJDOC has led to greater efficiencies in providing health care to inmates compared to the State of New Jersey’s per capita health care cost. The Kaiser Family Foundation (2009c) estimated that the per capita health cost in New Jersey in 2009 was US$7,583. This is US$1,916 more than the per capita physical and mental health care cost for NJDOC inmates for FY 2012.
Reduced Risk of Future Litigation
Prisons have often been viewed as ill equipped to provide medical services (Abramsky & Fellner, 2003). As a result, class action lawsuits have proliferated, as have sanctions by the U.S. Department of Justice, sometimes costing states millions of dollars annually in legal fees, clinical enhancements, monitoring costs, and fines.
The financial arrangement between NJDOC and UCHC may diminish the risk of litigation. That is, the cost-of-service reimbursement structure between NJDOC and UCHC removes any impression of the provider exercising cost avoidance strategies to maximize profits.
UCHC learned that to meet the requirements of a settlement agreement with external monitoring, it was insufficient to merely provide the required health care. UCHC proved that the health care system met the requirements by developing an extensive documentation of the care provided and of the quality of that care. The monitors lacked the resources required to provide this proof. As simple as it seems in hindsight, and as tedious as it is in practice, this documentation was and is crucial to UCHC’s success.
In addition to documenting clinical outcomes as described previously, UCHC has focused on inmate satisfaction with health care services. Inmate satisfaction surveys generated ratings between good (3) and very good (4), with average scores of 3.7 to 3.9 on a 5-point scale. The mental health survey responses from UCHC’s inmate-patients compared favorably to UBHC’s patients’ satisfaction ratings and to the ratings of Mental Health Corporation of America’s (2011) national survey of customer satisfaction with its member organizations operating in the community. Inmates’ satisfaction with their health care is plausibly related to the fact that the annual surveys are used to improve care. Changes are made in UCHC’s practices based on the information received from inmates. For example, inmates currently complain about the modest fee imposed upon them by NJDOC for routine medical appointments. As a result, UCHC is modifying the way its doctors and nurses interact with their patients, to let the patients know upfront of the requirements for payment.
Inmates’ satisfaction with their medical and mental health care is supported by a reduction in health care litigation, as reported to UCHC by the State’s Office of the Attorney General. Inmates’ satisfaction is also corroborated by fewer inmate complaints. Since UCHC assumed responsibility for mental health services in 2005, complaints dropped by 87% (1,863 in 2004 to 234 in 2011). Likewise, medical complaints dropped from 5,082 in 2007 under a private for-profit correctional health care entity to 3,328 in 2011 (35%). Dental complaints similarly dropped from 312 in 2007 to 170 in 2011 (46%). Figure 1 highlights these dramatic decreases in the number of inmate complaints between 2007 and 2011.
Inmate complaints regarding health services, 2007 to 2011.
Benefits to RU
Public Health Mission
For RU, expansion into correctional health care advanced its mission in health promotion, disease prevention, and the delivery of these services to underserved citizens throughout the State of New Jersey. The university would be hard pressed to find a more historically underserved population than those who are incarcerated.
NJDOC releases most inmates to the community after the completion of their sentences. This fluid relationship between the prison system and the broader community situates correctional health care at the forefront of many of our most pressing public health challenges. The correctional population exhibits disproportionate rates of infectious diseases (e.g., HIV and hepatitis C), chronic medical conditions (asthma, diabetes, hypertension), and mental illnesses, in addition to drug, alcohol, and tobacco addictions. It is clear that the clinical demands associated with correctional health care will continue to rise and these individuals, treated or not, will, with few exceptions, return to our communities and will continue to place demands on the state’s limited health care resources.
Citing these factors and others, a March 2002 report commissioned by the U.S. Department of Justice, pursuant to a Congressional directive, established that “prisons and jails offer a unique opportunity to establish better disease control in the community by providing improved health care and disease prevention to inmates before they are released” (National Commission on Correctional Health Care, 2002). With existing facilities in one of the most densely populated cities in the State of New Jersey (Newark), RU is already positioned to be a major player in addressing the needs of inmates as they reenter society.
Supported by a small training grant from the New Jersey Department of Health and Senior Services, UCHC introduced an evidence-based prevention model, Stanford’s Chronic Disease Self-Management Program (Lorig et al., 2001). Though results are preliminary, a group of inmate participants has seen significant improvement in their high-density lipoprotein levels. This model partners with our patients and challenges them to take responsibility for managing their chronic medical conditions. These groups are now being held in all NJDOC facilities.
Training Opportunities for Health Care Professionals
RU recently developed training tracks for professionals planning a career serving inmates in correctional settings. RU established a forensic psychiatry fellowship program with two psychiatric fellows. The two most recent graduates have taken positions as staff psychiatrists within UCHC. In addition, this partnership supports four psychology interns and multiple medical student and resident rotations.
Research
Due to past abuses, research on inmates was curtailed nationwide in the 1970s. NJDOC administrative code prohibits experimentation on inmates. However, NJDOC encourages nonexperimental research. For example, a study of the effect of Food and Drug Administration-approved medical treatments on inmates who receive such treatments is encouraged by NJDOC. UCHC, a branch of RU, is ideally situated to conduct this research. UCHC has published research (Reeves, 2012) and is working on several institutional review board-approved studies. Students in the RU School of Public Health will soon be conducting research in the prisons. Research that benefits inmates promises to be a growing part of UCHC’s operation.
Conclusion
Universities maintain a tradition of research, commitment to creativity, ongoing self-evaluation, and investigation of innovative technologies. These principles complement the mission of state departments of corrections. By affiliating with a university-based health care enterprise instead of contracting with a private provider or directly operating health services, a corrections department will reap, in time, the following benefits: a commitment to continuous quality improvement; improved staff retention and training; cooperation with other state agencies; and a focus on state-of-the-art, evidence-based treatment by a trusted provider of community-based health care. The success of health science universities in several states, including New Jersey, also demonstrates that academic institutions can, contrary to stereotype, control costs. In turn, a university will enjoy an enhancement of its public health mission, professional training opportunities, and opportunities for research in a population that will surely benefit from such research.
Footnotes
Acknowledgments
The authors acknowledge the following individuals who assisted in the development of this article: Ralph Woodward, MD, medical director, NJDOC; and Louis Colella, DDS, chief of dental services, NJDOC.
Declaration of Conflicting Interests
The authors disclosed no conflicts of interest with respect to research, authorship, and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.