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Care Behind Bars

When Jeanette Elias says "there's never a dull moment" at her workplace, you are inclined to take her word for it.

As nurse manager at the University of Texas Medical Branch at Galveston's Correctional Hospital, Ms. Elias oversees the care of patients whose ailments range from chronic to life-endangering. Like the rest of the hospital staff, she works behind bars.

"We treat offenders without any regard to what their offense was," said Ben G. Raimer, M.D., vice president for community outreach and correctional managed care at UTMB. "We don't know or care what they did. We call them 'Mr.' or 'Ms.' We treat them with respect."

Along with Texas Tech University Health Sciences Center, UTMB is responsible for the medical, dental and psychiatric care of more than 145,000 inmates in the Texas Department of Criminal Justice's custody. UTMB, which serves about 80 percent of those prisoners, provided more than 35,000 clinic and 37,000 telemedicine visits in FY2004. Health care is offered statewide in prison clinics, infirmaries and regional medical facilities, as well as in the Galveston prison hospital.

Beyond benefiting Texas prisoners with good medical care, UTMB officials say their work with the department of criminal justice serves the wider public, as well. With a dedicated prison hospital, for example, public safety does not have to be compromised by treating inmates in unsecured hospitals. In addition, inmates who receive good health care while they are in prison will pose less of a burden on their community health resources when they are eventually released. The former prisoners will be better educated about their health, acquainted with medication needed to treat any existing conditions, and in better health because of receiving regular medical care.

"We're looking at the future when we treat offenders," Cathy Nall, UTMB senior communications specialist, said.

In the meantime, inmate health care offers critical training for UTMB's medical students and young physicians. With HIV rates six times greater than the U.S. population as a whole and liver disease 11 times higher, the prisoners allow new practitioners the chance to learn from treating maladies they would see more rarely in the outside world. One-quarter of UTMB's surgical residents' training, as well, takes place in the prison hospital.

"We're locking people up for longer times - so we're getting an aging population of prisoners," said Raimer. "We're seeing much more in the way of acute diseases. The prison population used to be young, healthy folks. But that isn't true any longer."

Equally important to the public, UTMB has been able to develop more knowledge about disease treatments, as well as efficient and standardized models of health care in its work with prisoners.

"We've had the opportunity to refine the area of disease management," said Raimer. "We educate prisoners about their health and establish disease-management guidelines. Because we work on a captive population, we can look at outcomes of appropriate disease management.

"With diseases like diabetes, we help them control their blood sugar, and screen them to make sure their eyes and limbs and kidneys are okay. The same thing is true of high blood pressure - introducing ideas about a healthier lifestyle to stave off heart attacks and strokes."

To cut costs and increase efficiency, UTMB has also emphasized innovations like electronic medicine. Using highly specialized cameras and computers, physicians are able to interview and examine patients in the next town - or hundreds of miles away.

With more than half the state's prisoners diagnosed with some form of mental illness, said Marsha Canright, UTMB's director of media relations, psychiatric treatment is one of the institution's most important health services to inmates. Telemedicine can be particularly effective with mental-health care, according to Glenn G. Hammack, vice president and executive director of the UTMB Electronic Health Network. "Sometimes patients forget they're not in the same room with the doctor," he said. "They stand up and try to shake hands."

Telemedicine, as well as efficiently managed preventive care, allows UTMB to provide cost-effective services to Texas' prisoners. "When you compare us to other states, you see what we're able to do," said Raimer. "We receive $300 million to treat 145,000 prisoners. California treats 165,000 inmates for a billion dollars, and Florida is almost twice as expensive."

For years, health care of prisoners suffered from two stigmas, Raimer said. "First of all," he said, "that doctors who work in prisons are inferior, and they're working on a population that doesn't appreciate what they're getting.

"It's just the opposite. It takes very smart and innovative doctors to deliver health care in spite of the barriers. And by and large, the prison population is very grateful, really appreciative of the care they get."

To maintain high standards of health care, Raimer said, UTMB offers a battery of courses in continuing medical education and requires a high level of peer reviews. "We have multiple checks and balances," he said. "There are incentives for them to practice high-quality medicine."

An independent study of UTMB's correctional health care prepared early in 2005 by Texas Medical Foundation echoed and reinforced Raimer's statements. Assessing UTMB's administration, managed care delivery system, medical records and clinical outcomes, the report favorably compared UTMB's health care of prisoners as meeting or exceeding standards for managed care in the "free world." "UTMB...is seen within the professional community as a model of how to improve the quality of correctional health care while managing costs and planning for ongoing improvements to maintain efficiency and excellence in the system," the report said.

"What we're doing is a service to the community," Raimer said. "We're learning to produce improved outcomes with lower costs. We're showing you can spend an appropriate amount of money - and still have reasonable outcomes."