Health Care Delivery in the Texas Prison System: Title and subTitle BreakThe Role of Academic Medicine

The medical needs of inmates in US prisons and jails were largely ignored by society until the early 1970s, when the convergence of several independent forces brought the issue of correctional health care to the forefront. One of these forces was organized medicine.¹ In response to surveys indicating serious and pervasive health care deficiencies within correctional institutions, several organizations became involved in efforts to improve medical care for prisoners. The first comprehensive national health care standards for correctional facilities were published in 1976 by the American Public Health Association.² The American Medical Association developed model health care delivery systems for jails, published its own correctional health care standards, and established a program to accredit health care systems in jails.^{1 ,3}

Another force in bringing about reforms was the court system.⁴ A series of decisions by the lower federal courts during the early 1970s established a constitutional basis for providing an adequate level of medical care to prisoners.⁵ In the landmark case of Estelle v Gamble,⁶ the US Supreme Court affirmed that deliberate indifference to the serious medical needs of prisoners was a violation of the Eighth Amendment and ruled that the federal courts could intervene to ensure sufficient medical care. By 1981, 25 states were under court order or consent decree to improve conditions in their correctional institutions.⁴

These reforms were soon threatened by demographic changes in the nation's correctional populations. Responding to society's concerns about crime, lawmakers enacted legislation that limited judicial discretion in sentencing for certain offenses, resulting in sizeable increases in the number of mandatory and fixed sentences, and concurrent decreases in the use of alternatives to incarceration.⁷ Between 1980 and the early 1990s, the US prison population more than doubled.⁸ Additionally, incarceration rates for offenders with special health care needs, including elderly offenders and women, increased rapidly.^{9 - 10}

The explosive growth of the prison population, coupled with soaring medical costs and a shrinking base of public funding, severely strained the health care resources of many correctional systems in the 1990s. Moreover, health policy analysts began to point out that existing health delivery models were not designed to handle the increase in chronic illnesses and infectious diseases within the prison population.^{7 ,11} Faced with these challenges and a legal mandate to improve conditions in its prisons, Texas implemented a novel health care delivery system in 1994. By integrating academic medicine with managed care strategies, the Texas model has proved effective in meeting the complex health care needs of its prison population.

The Texas prison system is one of the largest correctional institutions in the Western world. In 2002, more than 145 000 adults were incarcerated in more than 100 facilities under the jurisdiction of the Texas Department of Criminal Justice (TDCJ); 11 000 additional offenders were housed in facilities operated by private corporations.¹²

Between 1990 and 2000, the annual increase in female prisoners in Texas averaged nearly 19%, the highest in the nation.¹³ Nearly 7000 women (5.5% of the prison population) were incarcerated in a TDCJ facility in 2002.¹² In 2002, 22 875 TDCJ inmates (18.2%) were 25 years or younger; 40 880 (32.4%) were aged between 26 and 35 years; 55 808 (44.3%) were aged between 36 and 54 years; and 6374 (5.1%) were 55 years or older.¹⁴ The number of inmates 55 years or older increased by 148% between 1994 and 2002 compared with a 32% increase in the overall TDCJ population. Black inmates constituted 41% of the population; white, 31%; and Hispanic, 28%.¹²

Baillargeon et al¹⁵ conducted a cohort study of more than 170 000 TDCJ inmates incarcerated between August 1997 and July 1998 to ascertain the prevalence of major and acute chronic conditions. During the study period, 60% of the population was diagnosed with at least 1 medical condition. The most prevalent disease categories were infectious diseases (29.6%), musculoskeletal system and connective tissue diseases (15.3%), circulatory system diseases (14%), mental disorders (10.8%), and respiratory system diseases (6.3%). Tuberculosis infection without active pulmonary disease was the most common specific condition (20.1%), followed by hypertension (9.8%) and asthma (5.2%). The most prevalent mental disorders were affective (3.9%) and schizophrenic (2%) disorders. The percentage of inmates with either viral hepatitis or human immunodeficiency virus (HIV) infection (estimated at 5% and 1.5%, respectively) was lower than expected, probably because universal testing for these diseases was not performed in the cohort. A more recent blinded seroprevalence study of TDCJ inmates indicated an overall prevalence of 29% for hepatitis C virus infection and 2.6% for HIV infection.^{16 - 17}

Prevalence rates for several diseases vary by age, race, and sex. The prevalence of arthritis, diabetes, and hypertension is considerably higher for inmates 50 years or older than for younger prisoners.¹⁵ Diabetes is more common among black and Hispanic inmates than among white inmates, similar to patterns in the general population. Female inmates have much higher rates of affective disorders than their male counterparts,¹⁵ and also have higher seroprevalence rates for both hepatitis C virus and HIV infections.^{16 - 17}

As recently as the 1970s, medical care in the Texas prison system was fragmented and largely inadequate. Although each prison had a small infirmary, most were poorly equipped and maintained and were primarily staffed by medical assistants and inmate aides with little formal training; there were few registered nurses and licensed physicians. Built in 1935, the Huntsville Unit Hospital was the primary medical facility for inmates but had become overcrowded and understaffed by the 1970s. Under an arrangement dating back to the 1920s, prisoners requiring specialty care were referred to John Sealy Hospital at the University of Texas Medical Branch (UTMB) in Galveston.

A series of rulings by the federal courts during the 1980s and early 1990s served as the primary impetus for health care reform in Texas' prisons. In a class action lawsuit filed against the Texas prison system in 1974, David Ruiz and other inmates sought relief for alleged constitutional violations, including inadequate health care.¹⁸ After extensive discovery and a lengthy trial, US District Judge William Justice ruled in favor of the plaintiffs in 1980. The court issued a consent decree granting injunctive relief and appointed a special master to oversee and monitor compliance. In December 1992, the court approved a final judgment containing detailed orders and compliance plans to ensure timely delivery of adequate health care to prisoners in Texas.¹⁹

One of the first steps toward improving health care was to replace the aging prison hospital with a new 8-story structure at UTMB in 1983. The first prison hospital to be located on an academic medical center campus, "Hospital Galveston" provides a full range of acute care services and specialty consultations. Medical care is provided by UTMB faculty and staff under administrative oversight of the university. Despite this initial step, it soon became apparent that Texas faced considerable obstacles in complying with the mandates of the court. One of the most pressing issues was how to resolve the high vacancy rates of correctional care physicians and nurses caused by inadequate financial and professional incentives and the fact that most prisons were located in isolated rural communities.¹⁸ These challenges were compounded by shrinking financial resources, increases in the prison population, and soaring medical costs. The cost of health care averaged $2262 per inmate in 1989, but climbed to $2839 by 1992, representing an annual increase of 8.5%. Such increases were partly due to the growing number of prisoners with chronic medical problems.²⁰

Based on a proposal to control costs by the state's comptroller of public accounts,²⁰ the 73rd Texas Legislature established the Correctional Managed Health Care Committee (CMHCC) in 1993.²¹ The committee was charged with developing a health delivery plan that used a managed care network of clinicians and facilities, and that integrated the network with the state's public medical schools and affiliated hospitals. The plan was implemented in September 1994.

The Texas correctional managed health care system is structured on a series of contractual relationships between TDCJ, CMHCC, and 2 state medical schools. TDCJ contracts with CMHCC to provide statewide oversight and coordination of health services. The CMHCC in turn contracts with UTMB and Texas Tech University Health Sciences Center (TTUHSC) to provide medical, dental, and psychiatric care to the prison population. Both universities subcontract with local clinicians on an as-needed basis. The program is funded by an annual appropriation from the State Legislature to TDCJ. Acting as an independent third party, CMHCC allocates funds to UTMB and TTUHSC based on a specified capitation rate. Capitation rates for the 2 universities differ because of variations in the type and extent of services they provide and the health characteristics of the population under their care.

The TDCJ Health Services Division monitors the quality of care delivered by the contracted clinicians via its Health Services Quality Improvement Program. Biennial operational reviews of prison health facilities are conducted to ensure compliance with national and state standards and laws. Additionally, the division investigates all medical-related grievances, reviews all prisoner deaths, and monitors the incidence of communicable diseases.

The CMHCC is composed of 9 appointed members, including 3 public members and 2 representatives from TDCJ, UTMB, and TTUHSC. Five members are physicians.²² Besides coordinating the contractual provision of health services, the committee monitors the general quality of health care, resolves disputes related to medical care, and implements the use of case management, utilization review, and other managed care tools. The committee has the power to enforce compliance with contract provisions.

The TTUHSC service area includes the western portion of Texas (about 22% of the prison population); UTMB serves the remainder of the population. UTMB primarily uses its own employees to provide correctional health services; TTUHSC uses a mix of its own employees and subcontracted local clinicians.

Primary care is provided at ambulatory clinics located in every TDCJ facility. Basic dental and mental health services are also available at all but a few clinics. Additionally, infirmaries with capacities ranging from 7 to 116 beds (total of 375 beds) are located in 16 correctional facilities. More advanced levels of care are available at Hospital Galveston and several regional medical facilities. All medical facilities are accredited by either the American Correctional Association or the National Commission on Correctional Health Care. Hospital Galveston has been awarded accreditation with full standards compliance by the Joint Commission on Accreditation of Healthcare Organizations.

A number of programs are available for inmates with special health needs, including those with chronic diseases and psychiatric disorders. Chronic care clinics have been established to provide more effective interventions for the increasing number of offenders with chronic diseases. Elements of chronic care management include patient education, regular evaluations by a clinician, monitoring for medication efficacy and compliance, and evaluation of laboratory tests. Interventions are based on evidence-based practice guidelines developed by a joint pharmacy and therapeutics committee. Several of the guidelines have been published by the National Guideline Clearinghouse.²³ The clinics provide care for about 20 000 patients with hepatitis C virus infection, 18 000 with essential hypertension, 17 000 with psychiatric disorders, 8000 with asthma, 6000 with diabetes mellitus, and 2400 with HIV infection.

Approximately 25 000 inmates (17% of the population) have a medical alert code, indicating a current or past history of a mental disorder. Services available to this population include group and individual psychotherapy, psychopharmacologic therapy, and crisis intervention counseling. Inpatient care is provided at 3 psychiatric facilities with a combined total of 1628 beds. Outpatient services are available at almost all ambulatory clinics. Extensive use of telepsychiatry has also expanded treatment access and scope. As an alternative to administrative segregation, TTUHSC implemented an inpatient program in 1990 for mentally ill offenders with a history of aggression. The Program for the Aggressive Mentally-Ill Offender uses cognitive behavioral therapy to help inmates curb aggressive impulses. Texas also was one of the first states to develop a model program for the mentally retarded offender.²⁴

Telemedicine has been an integral component of health care delivery under the managed care model. Both universities implemented limited correctional telemedicine services in 1994.²⁵ By 1997, approximately 10% of all specialty consultations were conducted via telemedicine. The yearly number of correctional telemedicine consultations conducted by UTMB alone currently exceeds 30 000. Besides general medicine and surgery, 28 specialty and subspecialty services are available via telemedicine. Telemedicine has proved to be especially effective for Texas' sprawling prison system, because it improves timely access to specialty care for offenders in remote locations. Telemedicine also has helped reduce the overall cost of transporting inmates over considerable distances for consultations.²⁶

UTMB deploys a correctional telehealth network that combines the videoconferencing capabilities of telemedicine with a customized electronic records management system. The technology enables secure, comprehensive storage of medical records that can be readily accessed by clinicians at the prisons and the hub site. Clinicians also have immediate access to the TDCJ formulary and disease management guidelines. Utilization review and case management are facilitated by the fully digital system, which also integrates a pharmacy management program to permit monitoring of compliance with treatment guidelines.

Significant improvements in the provision of medical and psychiatric care to Texas' prison population have occurred during the 9 years that the managed care program has been operational. One of the most noteworthy has been the increase in health care staffing. Vacancy rates for physicians, mid-level practitioners (physician assistants and nurse practitioners), registered and licensed vocational nurses, and other medical personnel have been reduced from previous levels ranging between 30% and 40% to levels ranging between 8% and 12%. A 1999 survey by the National Commission on Correctional Health Care showed that the ratio of unit health care staff to inmates was 1:34, with a health care staff turnover rate of only 8%.⁵

The managed care program uses an operational performance evaluation system (OPES) to monitor clinical performance and outcomes. The clinical portion of OPES includes more than 100 quality of care indicators for 8 common diseases that are used to measure compliance with performance standards for several critical areas of service, including access to care, clinician intervention, disease monitoring and preventive care, and chart documentation. Several direct patient outcomes are also measured.

A recently completed retrospective analysis using randomized chart audits of OPES indicators for management of 6 chronic diseases (asthma, coronary artery disease, type 1 diabetes mellitus, hypertension, hyperlipidemia, and seizure disorders) showed substantial improvements in compliance with performance standards under the managed care program (J. Pulvino, PA-C, oral communication, May 17, 2004). The mean compliance rate for all clinical performance measures for all diseases increased from 40.1% in 1994, before managed care strategies were implemented, to 96.8% in 2003. Under managed care, there were considerable improvements in the mean level of compliance with all clinical indicators for each of 6 chronic diseases (Table 1). Major improvements in compliance rates also occurred for all areas of clinical service.

Additionally, there were statistically significant changes in several disease-specific end points. The mean (SD) blood glucose level for patients with type 1 diabetes mellitus decreased from 229.7 mg/dL (76.8 mg/dL [12.7 mmol/L {4.26 mmol/L}]) in 1994 to 188.2 mg/dL (98.6 mg/dL [10.4 mmol/L {5.47 mmol/L}]) in 2003 (P = .003). The mean (SD) low-density lipoprotein cholesterol level among patients with hyperlipidemia decreased from 174.4 mg/dL (40.8 mg/dL [4.52 mmol/L {1.06 mmol/L}]) in 1994 to 131.5 mg/dL (42.6 mg/dL [3.41 mmol/L {1.10 mmol/L}]) in 2003 (P = .005). The proportion of patients with essential hypertension with a blood pressure level of at least 140/90 mm Hg decreased from 82.8% (95% confidence interval [CI], 73.9%-92.9%) in 1994 to 50.9% (95% CI, 47.8%-54.0%) in 2003.

Reduced mortality rates for several chronic diseases were associated with implementation of specific disease management strategies. The rate of AIDS-related deaths decreased significantly, from a high of 1.5 deaths per 1000 in 1995 to 0.24 deaths per 1000 in 2002 (Figure 1).²⁷ The rate for TDCJ asthma-related deaths also declined, from a high of 3.3 deaths per 100 000 in 1995 to none in 2002 (Figure 2).^{28 - 34}

Many of the strategies used by the Texas managed health care program to improve offender health care have also resulted in substantial cost savings. During the program's first 6 years, overall savings to the state were estimated at nearly $215 million (not adjusted for inflation).

Some health policy analysts have voiced concerns as to whether a managed care model can ensure adequate health care when applied in the correctional setting.³⁵ Although no single health care delivery system is optimal in all correctional settings, nearly a decade of experience in the Texas prison system demonstrates that certain strategies can result in high-quality health care that is also cost-effective.

Keys to success for the Texas experience include the use of standard disease management guidelines, a common formulary, patient and clinician education programs, use of chronic care clinics, and technologies such as telemedicine and electronic medical records. Regular review and feedback for clinicians regarding compliance with disease management guidelines, adherence to pharmacy practices, and quality issues using the OPES system have been essential in the maintenance of cost savings as well as clinical outcomes.

Integrated systems used for the management of Texas' correctional health care populations may be useful in other populations, especially those with a high incidence of chronic disease and disability. Implementation of similar strategies for Medicare, Medicaid, and the State Children's Health Insurance Program populations should be considered. Integrated telemedicine, electronic medical records, and disease management programs in the context of managed health care may also be of benefit in the management of large chronic care populations, particularly the elderly population.