Rx for Scandal
The quality of health care in the Texas penal system is criminal.
PURELY IN TERMS OF PUBLIC RELATIONS, it has been a lousy ten months for the Texas penal system. First came the revelation last August that guards at the Brazoria County jail were videotaped physically and verbally abusing inmates. Then, in January, former Texas Department of Criminal Justice (TDCJ) chief Andy Collins was indicted on eight counts of conspiracy, bribery, money laundering, and other charges related to the VitaPro controversy (“The Great Texas Prison Mess,” TM, May 1996). But the greatest scandal may be one only now unfolding. It has to do with health care in the state prisons, and it’s a matter of life and death.
Since 1993, in an effort to contain costs that were among the highest in the country—nearly $2,900 per prisoner per year—TDCJ has had in place a system called Correctional Managed Health Care. Under that plan, two public medical schools, the University of Texas Medical Branch at Galveston (UTMB) and Texas Tech University Health Sciences Center in Lubbock, attend to the state’s more than 140,000 inmates. (UTMB oversees the prison-heavy eastern half of the state, or 80 percent of all inmates; Texas Tech handles the rest.) The budget for the next biennium: $582 million, enough in theory to ensure that Texas inmates receive the best and most cost-efficient care possible. And, in fact, thanks in part to cost savings implemented by the schools, the per-prisoner cost has dropped to $1,900 a year. But the quality of care has also dropped—dramatically.
Two years ago, for example, investigators at TDCJ and UTMB reviewed the medical records of 24 inmates who had died at the Stiles Unit in Beaumont, where hundreds of prisoners with AIDS are housed, and concluded that 16 had received “improper care.” They reported that inmates with serious illnesses—even those displaying such critical symptoms as persistent fever, weight loss, and shortness of breath—were left in their cells unattended or denied visits to specialists. Referring to a case in which a prisoner died from complications related to AIDS and an undiagnosed cryptococcus infection, one investigator wrote: “There was no evidence of any active treatment at Stiles, and it appears that this inmate was essentially left to die in the infirmary.” Likewise, last September the Texas Department of Health found dozens of deficiencies at the UTMB-run Estelle Prison Dialysis Center in Huntsville. According to the investigators’ report, prisoners who were hooked up to machines were unsupervised for long periods of time, some of the center’s staff were improperly trained, and poor equipment-cleaning techniques could have resulted in patients receiving contaminated blood—even the blood of other sick inmates.
Considering those findings, it’s no surprise that from 1993 to 1996, according to TDCJ data contained in a state audit released in January, inmate medical grievances increased by more than 17 percent, and total “medical correspondence”—usually complaints from prisoners, their families, and prison staff—rose by more than 60 percent. Some prisoners said they’d been denied medication, tests, and supplies—one prisoner who had undergone major back surgery said a doctor confiscated his walker, leaving him to crawl or lean on other inmates or use a single crutch to get around—and some prison staffers, especially those at UTMB-managed facilities, admitted to being “shocked” at the low standard of care. Jana Hawkins, a nurse who worked at Stiles until she quit last summer, says UTMB administrators frequently sent out memos reminding the staff not to give prisoners “comfort measures” such as Tylenol for headaches and athlete’s foot cream (unless there were “breaks in the skin”). Hawkins says that some inmates who could not walk—including a “brittle” diabetic with one leg—were not allowed wheelchairs. And understaffing was a common problem. “You’ve got a bunch of very stressed people trying to give good quality health care,” Hawkins says, “and that’s just not possible.”
In an interview, the medical director of UTMB’s managed-care program, Dr. Jason Calhoun, denied many of those allegations. He insisted that prisoners are being seen more often, for instance, and that the percentage of staff vacancies has decreased since UTMB and Texas Tech took over. Moreover, he said, AIDS deaths systemwide are down by 25 percent. “We have significantly improved quality measures, whether we’re talking about mortality, access to care, or timeliness of visits,” he said.
Yet quality of care isn’t the only troubling issue. There’s also oversight. “Correctional Managed Health Care lacks a comprehensive monitoring system,” the state’s audit reported. Critics say the same: They note that four of the six members of the system’s oversight body—called the Correctional Managed Health Care Advisory Committee—work for UTMB or Texas Tech, the two schools that have the contracts. “This type of relationship, in the private sector, would raise questions about conflicting loyalties between the parties,” said state auditors, who, along with Board of Criminal Justice chairman Allan Polunsky, have suggested that the Legislature look at giving TDCJ (which has the other two seats on the committee) more control—or else disband the committee altogether. Complicating matters is the fact that Dr. Michael Warren, who was TDCJ’s medical director from May 1994 until this past January, was a full-time UTMB faculty member. Moreover, both the executive director of the managed-care plan, James Riley, and its chief financial officer, James Lynaugh, have been accused by state officials of being “lobbyists” for the universities. (Riley and Lynaugh refused to be interviewed for this story.)
The financial monitoring of the plan has also come under scrutiny. After reviewing the managed-care contracts signed by TDCJ and the universities, auditors concluded that the providers aren’t held responsible for how they spend state funds; last year, for example, UTMB was free to pay out nearly $670,000 in doctor bonuses. Further, the universities can spend the “profits” however they choose: In 1996, when they netted $37.3 million, they gave back $12.5 million to the state, carried $9 million forward as a “catastrophic reserve,” and pocketed the remaining $15.8 million. Not surprisingly, state legislators are now taking a harder look at the budget for prison health care. At prisoner-safety hearings last March, when Lynaugh boasted that the state could expect to get back millions more in the future, State Senator John Whitmire of Houston cracked, “Someone could just say, ‘You’re obviously overfunded.’ In fact, I will.”
Thanks to the investigation, improvements to the system seem to be under way. A TDCJ follow-up audit of Stiles conducted late last year showed great improvements in the processes used to treat infectious diseases, and the dialysis problems at Estelle have been corrected. Also, in May the staff of the Sunset Advisory Commission recommended that the Legislature make changes to the managed-care oversight committee—including adding three non-university members and giving TDCJ more control. All are hopeful signs—but from the looks of things, it will still be a while before the Texas penal system recovers from its latest PR black eye.