A group of men gathered around a table in the geriatric wing of the Estelle Unit in Huntsville, Texas, for a game of dominoes. Behind them, a small television flickered with the day’s soaps, and beyond that, a white-washed room separated by waist-high partitions exposed rows of state-issued cots strewn with magazines, Bibles, empty cups and headphones. Here on the inside, this is high-dollar real estate. It’s air-conditioned and quiet, almost peaceful, absent of the endless buzz that bounces through the main hall where the general population of this maximum-security prison resides. On clear days, natural light beams through the small windows here and, if you’re lucky, you might catch a glimpse of the feral kittens playing outside along the towering fences.
The inmates in the geriatric unit suffer from multiple medical diagnoses, which is how they gained access to this haven in the first place—a silver lining to their chronic obstructive pulmonary disease, high blood pressure or kidney failure. One man with advanced kidney disease had been paroled a few years prior after serving two decades. He was doing well on the outside, abstaining from alcohol and working for a group home in Fort Worth, cooking and cleaning and sometimes assisting with baths and overnight diapers. But he ended up back in the system because he couldn’t get the dialysis he needed in the free world. At least in prison, he said, he had health care.
A DIY approach
The country’s state prison population has grown by more than 700 percent since the 1970s, according to a report by the Vera Institute of Justice. In 1994, the Texas Correctional Managed Care program was created in response to growing concerns about overcrowding and access to health services in the state’s prisons. With a mission to improve care while maintaining costs, the partnership between The University of Texas Medical Branch (UTMB), the Texas Department of Criminal Justice (TDCJ) and Texas Tech University Health Sciences Center has significantly changed how health care is delivered in Texas prisons.
Before, caring for Texas inmates took as much as 14 percent of the prison system’s operating costs. One-on-one treatment was delivered by prison system employees and through fee-for-service arrangements with local hospitals, which generated little incentive to control spending. Staffing challenges at rural hospitals and rising rates of HIV and hepatitis C also burdened the system.
Today, through the Correctional Managed Care program, complete medical services are provided by the partnering universities, with UTMB treating close to 126,000 patients, or 80 percent of the state’s offenders. The universities also manage the recruitment and hiring of all health care personnel, pharmaceutical operations, outpatient and ancillary services, and inpatient hospital encounters.
“We get the value of a health care entity providing health care services versus the correctional system, plus we have a better aligned compensation system in place because hospitals and universities are running the program,” explained Owen Murray, D.O., MBA, executive director of clinical services and chief physician executive for the UTMB Correctional Managed Care program. “It’s a win-win situation.”
Entry to the W.J. “Jim” Estelle Unit involves passing through multiple checkpoints akin to post-9/11 airport security and prison guards unlocking cell blocks with extra-large brass keys. Offenders are dressed in head-to-toe white and instructed to walk alongside the walls between thick yellow lines painted on the polished concrete in the main hall. This is their entrée to their everything—the mail room, commissary, barbershop, law library, medical clinic, pill line, rec rooms and classrooms. It is a city unto itself, fostering self-sufficiency and accountability.
Medical care is available here 24 hours a day, seven days a week. The clinic inside the main building functions like a typical doctor’s office and minor emergency room. Those with more serious health concerns are transported to the Regional Medical Facility (RMF) on campus, where patriotic murals painted by inmates cover the walls. Like the geriatric unit, offenders residing in the RMF must meet specific medical criteria. Many require an inpatient setting for ongoing nursing and IV care.
“They’re not sick enough to be in the free world, but not well enough to be anywhere else inside,” explained Shelly Hanson, director of nursing.
All told, Estelle’s comprehensive medical capabilities range from primary care to UV therapy for skin conditions to dental services. The regional laboratory for the prison system is also on-site, as well as an ambulance service for offenders on other campuses or emergencies at the RMF. For highly specialized care, prisoners are transported to a free world hospital or a prison hospital in Galveston managed by UTMB.
Delivering services on-site reins in millions in otherwise necessary expenditures. According to Laura King, nurse supervisor, the RMF’s dialysis unit alone saves the state $6 million a month.
“We have a lot of individuals who are not going to be getting out, so we are going to be dialyzing a long time,” King explained. “It’s unbelievable the amount of money this facility saves the state when you look at the ancillary staff and security required to send them out to a free world hospital.”
According to Murray, that $6 million in savings translates to a cost that is seven times less than other states, most of which contract with an outside company for dialysis treatment.
“It just makes sense to do it ourselves,” he said.
Only a small portion of the prison population needs dialysis—a process that takes on the natural work of kidneys and eliminates waste and water from the blood—but it is an expensive procedure most commonly required for older patients. And as the prison population continues to age, the cost of caring for older inmates will rise.
The number of state and federal prisoners age 55 or older increased 204 percent—from 43,300 to 131,500—between 1999 and 2012, while the number of inmates under 55 increased by just 9 percent over the same time period, according to a recent report from the Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation. Pew cites a National Institute of Corrections study that pegs the annual cost of incarcerating prisoners 55 and older with chronic and terminal illnesses at, on average, two to three times that of the expense for other inmates.
It’s an issue made worse by the fact that prisoners are more likely than the general population to report ever having a chronic condition or infectious disease, with 40 percent of state and federal prisoners and jail inmates reporting current chronic medical conditions, according to a National Inmate Survey published by the U.S. Department of Justice.
Many offenders in the Estelle Unit will die on the inside. More and more will require increasingly expensive medical care and infirmary placement. But where will they go, when much of Estelle’s medical slots are already at max capacity? Releasing older offenders with a low likelihood of committing a crime has been proposed, but how would the justice system determine criteria, especially when life sentences are on the line? It’s a problem the state legislature will have to address, and soon.
“When I started in ’95, we had open infirmary beds, but now they’re filled 100 percent of the time, and the number of those patients who are permanently assigned has grown each year,” Murray said. “Right now, about 70 percent of our total beds are filled with offenders who will never get out of here.”
Each prison in the state of Texas has a Count Room, where rows of colored tags hang from tiny hooks on a wall. It’s a visual census, a physical database of every offender in the facility, their tags marked with height, weight, age, medical restrictions, custody levels and whether or not they require a bottom bunk due to strength and mobility. The tags are color-coded by race—blue for black, red for Hispanic, white for white. Offenders are separated into different wings based not on race, but on age and stature; individuals in each group can be no more than 15 years, 6 inches, and 60 pounds apart. Like everything the prison system does, it’s deliberate. It is not like it is in the movies.
Doling out prescription drugs to inmates is no different.
Early on, UTMB determined that the most efficient and cost-effective way to dispense drugs to inmates was through its own pharmacy, now housed in an unmarked Huntsville building that used to be part of a strip mall. It’s a huge, highly organized production with custom-made conveyor belts and automated machines that fill, seal and label 30-day-supply blister packs, which is how almost every drug in the prison system is bundled. The method is proven to enhance sanitation, safety and accountability throughout the supply chain. The blister packs also allow for reclamation; facilities can return unopened pills for credits, which has saved the state an average of $8.2 million a year, according to Melanie Roberts, assistant director of operations at the pharmacy.
Orders are sent through the electronic medical record system, and the pharmacy fills approximately 20,000 prescriptions a day, serving 130 facilities throughout the state, including TDCJ and the Texas Juvenile Justice Department, as well as a handful of county jails.
“It’s another example of where we’re taking full responsibility,” said Murray, who has been working in the prison system for nearly 30 years. “We’ve realized the cost of dollars we can save by doing it ourselves is much more of a value to the state than contracting it out.”
And because UTMB runs the entire operation, they are eligible for 340B Drug Discount Program pricing, which requires drug manufacturers to extend the lowest possible cost to hospitals with substantial low-income patient loads.
The pharmacy offers a 24-hour next-business-day turnaround time and works in conjunction with the Correctional Managed Care program’s robust telemedicine practice to ensure patients in need of pharmaceuticals—everything from amoxicillin to Zyrtec—receive them as quickly as possible.
Since most facilities in the state cannot cater to medical needs the way the Estelle Unit does, telemedicine fills the gaps, allowing inmates to be seen quickly without spending additional dollars staffing full-time providers or reimbursing mileage. The telehealth program serves 83 facilities across the state.
“As a primary care provider, I can take care of most cases through telemedicine,” explained Ruth Brouwer, a physician assistant who transitioned to the UTMB telehealth team after being attacked by a cuffed inmate with a knife. She now works in an office building in Conroe and serves far more patients on a daily basis than she did in the field. “I can order labs, follow up on labs, talk directly to patients and share data through the EMR.”
According to Murray, efficient delivery of primary care services is one of the most important aspects of the telehealth program, for both quality and cost.
“If we didn’t have telemedicine, we may miss an opportunity for early intervention and treatment,” Murray said. “Seeing Ruth provides a great opportunity for us to improve care and decrease cost.”
In addition to cost savings, general health compliance has surged, as well. Compared to national benchmarks like HEDIS—the Healthcare Effectiveness Data and Information Set, a tool used by the vast majority of health plans in the U.S. to measure performance—the Correctional Managed Care program surpasses national benchmarks in the management of diabetes, hypertension and asthma.
“We compare incredibly well, and rightly so, probably because we know where our patients are, we don’t lose them to follow up, and I can tell whether they’re taking their meds or not,” Murray said. “So we’ve got some controls in place that really do help us do a better job than compared to the free world, where I’d see you in my office and I just hope that you’re going to take your meds and follow your diet and come back.”
Despite the program’s victories, challenges threaten its momentum. Diseases like HIV and hepatitis C strain its resources. HIV drugs account for 40 percent of the pharmacy’s total budget, with less than 2 percent of the offender population infected.
“HIV drugs are always changing, the disease is changing, and every year we get new guys coming in so we’re always starting the clock again, always doing more workups, always finding more disease,” Murray said.
Frustratingly, all too often he sees offenders whose disease was controlled in prison neglect treatment after being released.
“Three years later they come back and the HIV isn’t controlled because they didn’t take their meds,” he said. “Now all of a sudden what was maybe a $500-a-month regime is now $5,000.”
Although horrified, Murray gets it. “Am I really going to be worried about following up with mental health or going to the doctor for my HIV care when I don’t have a home, I don’t have a job, and I have no food?”
Controlling hepatitis C is even more challenging, with its prevalence considerably higher in prisons compared to the free world.
“Curative treatment runs about $80,000, but if you do the math, that becomes a significant economic challenge for the state,” Murray said. “Then there’s the ethical question of whether every inmate should get that kind of treatment. And then there’s the public health concern that we’ve got all these high-risk groups, known patients, and we could actually begin to eradicate the disease if we really had an aggressive treatment program in prisons and jails. It’s a clinical issue and a public health issue, but, ultimately, it’s a cost issue.”
While the program has restrained costs in every corner it could find, ongoing funding is essential. The RMF is in dire need of new dialysis chairs, the telehealth network could benefit from higher bandwidth and updated technology, and staff need their salaries. Even in the pharmacy, where achievements in automation and efficiency feel futuristic, the most proficient tool for the simple yet critical job of peeling labels off returned blister packs turned out to be hands.
“We try to be judicious and respectful of the fact that there’s not an infinite amount of dollars out there to take care of these patients, yet we’re going to do what’s necessary in terms of a reasonable clinical level of care and expect a reasonable clinical outcome,” Murray said. “We’ve looked at every aspect of our care provision and our health system and are always looking for ways to improve things and cut costs, but eventually, you kind of run out of new tricks.”
An alternate ending
Thirteen miles south of the Estelle Unit is the Huntsville Unit, nicknamed “the Walls.” It is the oldest prison in the state and home to the execution chamber, the busiest in the nation. Like all prisons in the area, it is built with a ruddy red brick, which stands in stark contrast to the glistening brass railings guarding the entrance. As the legend goes, these railings have been polished daily since the prison’s opening in 1849.
Each day, there is a release. Men from the Estelle Unit and other regional facilities serve their time, and when they make parole they are transferred to the Walls. Across the narrow street, mothers, fathers, lovers, sons, cousins and friends sit on picnic benches under trees, waiting. If an inmate is lucky, he will be met there with a handshake or an embrace. He may feel grateful, even blessed that he didn’t leave in a wooden box on its way to Boot Hill, where unclaimed prisoners lie buried. Or he might scan the crowd, hold his breath until he is absolutely sure, then walk to the Greyhound station alone. He will worry about housing and food, his past and his future. And if he is ill, he will worry about how to manage his health—today and every day—in the free world.
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