Health care for prisoners costs Ohio more than $200M annually

COLUMBUS — In the last 10 months, just six patients at the Ohio State University Medical Center ran up more than $3.9 million in hospital charges — all billed to state taxpayers.

Each one suffered from conditions such as cancer, heart failure and pulmonary disease that could have killed them without 24-hour medical care.

And each one has something else in common beyond their free medical care and potentially fatal conditions. They all are Ohio Department of Rehabilitation and Correction inmates, some shackled to their hospital beds and watched by armed guards.

Ohio’s prison system spends $222.8 million a year on medical care for its approximately 51,000 inmates, including $28 million for prescription medications.

Each week, a high-cost case summary comes to Medical Services Chief Stuart Hudson. He watches it closely, mindful that any of these cases could become “million-dollar inmates” who could swing his budget out of whack.

They are being treated for serious conditions such as hepatitis C, renal failure, quadraplegia from gunshot wounds, liver cancer, bone marrow transplants, brain tumors, sickle cell anemia, abdominal aortic aneurysms and gangrene.

One inmate was admitted Nov. 29 for surgery to reverse an ileostomy — a surgery done when there is a problem processing intestinal waste — but he developed post-op complications and required a ventilator and trachea tube. The prisoner’s hospital stay at OSU’s locked prison ward extended for months and ran up charges of $802,827. DRC typically pays 25 percent of the billed charges.

On April 27, a court granted a judicial release for the inmate and he was discharged to a hospital, DRC officials said.

As in the private sector, health care costs have exploded in the prison system over the last decade. Last year’s average of $4,371 per inmate was an 85 percent increase over the $2,365 per inmate cost in 2001.

But Ohio is in the middle of the pack among state prison systems: California pays $14,012 per inmate while Texas gets by on $2,733, according to a report by the Correctional Institution Inspection Committee.

The Kaiser Family Foundation has estimated that the average annual health care cost for Ohioans is $5,725, which comes to about $1,400 more than the average for Ohioans in prison.

The steady climb in Ohio’s prison medical costs is attributable to health care inflation, an aging inmate population and a federal class action lawsuit filed by state inmates in 2003 and settled in 2005.

Attorneys for the inmates argued that Ohio’s failure to provide adequate health care amounted to cruel and unusual punishment. Prisoners are the only Ohioans who are constitutionally guaranteed health care.

“Conditions were absolutely deplorable. In 2003 when we filed (the federal lawsuit), there was no question in our minds that the level of care was so inadequate as to be unconstitutional,” said attorney David Singleton of the Ohio Justice Policy Center. “And just so we’re clear about that, you don’t have to do much to satisfy the constitution. It’s not Cadillac care by any stretch of the imagination. And what we found was woefully inadequate. Folks were not getting emergency situations treated. If you had a chronic disease — good luck getting an appointment to deal with that. There were instances where prisoners were literally dying as the result of the lack of care.”

The settlement led to the hiring of 310 more medical staff and spending an additional $28 million a year on health care, according to the Correctional Institution Inspection Committee, a bipartisan legislative agency that keeps tabs on prison issues.

Singleton recognizes that some taxpayers may object to spending so much money on inmate medical care. But aside from the constitutional requirement, Singleton said preventative care makes good fiscal sense — addressing chronic diseases before they get very costly to treat. Likewise, he said, it is good public health policy to treat inmates with infectious diseases before releasing them to the community. Eventually virtually all prison inmates — about 98 percent, Singleton said — get released from prison.

Managing chronic diseases

Robert Frost, 46, of Dayton is somewhat of an expert on the prison health care system. After all, he’s been an inmate at the Southern Ohio Correctional Facility in Lucasville for 18 of the last 20 years.

Frost, wearing a bright orange jump suit and foot shackles as he prepared for a CT-scan at the Corrections Medical Center, said, “I think it’s a little better, given what it used to be. They act on serious matters a little quicker than they used to.”

He first complained about a testicular problem about three months ago and by early May he was getting a scan.

“They want to find out if this is cancer or not so they got right on it,” said Frost, who was sentenced to 15 years to life for stabbing a man to death in a Dayton alley.

Also suffering from high blood pressure, Frost is one of the more than 18,000 inmates enrolled in a chronic disease management program designed to cut costs and prevent problems. Staff now checks him regularly and makes sure he is taking his medications. “They didn’t used to do that,” he said.

The prison system introduced heart-healthy menus in the cafeterias in 2007 and banned tobacco use beginning in 2008.

But despite the progress toward meeting the constitutional mandate, the state still has room for improvement, according to Fred Cohen, an independent monitor hired by the federal court. Cohen identified a number of lingering problems, including salaries that he said are inadequate, and a need for more staff doctors and nurses. He also said there is a persistent backlog of chronic disease appointments, and a lack of accountability for the care provided by medical vendors.

DRC recently replaced five civil service advanced level providers — doctors, nurses and physician assistants — because of poor performance, including a doctor assigned part-time to a state prison in West Dayton.

The physician’s medical charts were hurried, chaotic and in “indecipherable handwriting,” she exhibited inappropriate anger, had a history of poor interpersonal skills, often called in sick and failed to order labs on a timely basis, according to a monitoring report issued in September. The report did not include the full name for the physician, who no longer works for DRC, according to prison officials.

DRC is switching from contract doctors to state-employed physicians so that the department has more control over the quality and cost of care, said Hudson, the Medical Services chief. About 70 percent of prison doctors are state workers.

Cohen’s latest report to the court detailed problems but noted, “With few exceptions ... there exists a system of medical care that provides access for inmates to appropriate bed space and clinicians.”

An expansive system

The state prison medical system is both expensive and expansive. Each year, it provides 6,000 video consults, dispenses 1.4 million prescriptions, manages 18,300 inmates with chronic conditions such as diabetes, asthma, hepatitis and heart disease, covers 2,250 local emergency room visits, runs a hospital lab that processes 3.5 million tests, and tends to 309 broken jaws and 260 broken hands — usually the result of prisoners fighting.

The money to run it isn’t just for doctors, nurses, MRIs and lab tests. Each day DRC guards shuttle inmates to emergency rooms, the Corrections Medical Center, the Frazier Health Center (housed within the Pickaway Correctional Institution at Orient) and the OSU Medical Center. Two or three guards are typically required for each high-security inmate.

Corrections Officer Cassandra James has seen it all while guarding inmates at OSU Medical Center: babies being born, limbs being amputated, open heart surgery. Guards like James escort inmates to surgery, wearing sterile coveralls and sidearms.

“We get to see all that stuff without having to go to medical school,” the Dayton native said while posted outside a hospital room with four men shackled to the beds. “Sometimes it can be sad ... but then you have to shake it off.”

The Frazier Health Center houses DRC’s kidney dialysis center — the state’s largest with 28 chairs. The center operates two shifts a day, seven days a week.

As a reporter and photographer watched earlier this month, inmate Taywyn Mason sat in a vinyl-covered reclining chair as his blood was drained out, mechanically filtered and returned to his body. The veins along his left forearm bulged out in two places, as though small balloons were lurking below his skin — the result of 17 years of kidney dialysis, three times a week for four hours at a pop.

Mason, who is serving a 15-year sentence for robbery and kidnapping, said the new dialysis center is a big improvement over DRC’s older and now-closed facility at Orient Correctional Institution, which was so untidy Mason said he was afraid to use the bathroom.

The new center, on the other hand, gleams like a shiny, new penny. The room is open, brightly painted and the windows overlook farmland and prison grounds. It smells of vinegar —a primary component in the cleaning solution used on the $13,000 dialysis machines.

Many of the staff caring for the inmates prefer not to know their patients’ crimes.

“They’re all patients, regardless of their crimes,” said Missy Roush, nurse supervisor at Frazier. She started in corrections health care 13 years ago as a single mom needing a stable job. “If one of my kids — God forbid — were to end up in prison, I wouldn’t want them to be treated bad,” she said.

Terry Harris, Pickaway Correctional’s acting Medical Operations manager, said she felt a calling from God to work in corrections health care after watching the 1993 Lucasville prison riots on TV. She said she never feels conflicted about caring for criminals.

“They are patients to us, not inmates,” Harris said. “We are going to take care of these guys. That’s the right thing to do.”

There could soon be less money to provide that care.

State lawmakers are now debating the upcoming two-year budget, which calls for an 18.4 percent cut to prison medical services between 2011 and 2013. If adopted as is, the state would trim the medical services budget from $239.1 million this year to $209.2 million in 2012 and $195.2 million in 2013.

“We are hoping it is not going to undo the progress. We’re going to be watching that very carefully. If it undoes the progress to the point that care is unconstitutional, we’ll be back in court,” said Singleton. “I don’t think it’s going to improve care. I can pretty much say that. But whether it makes the system unconstitutional, we’ll have to wait and see.”

Prison system officials have taken other steps to control medical costs. Ohio uses a managed care contractor to review hospital stay bills to see if the state is overpaying and keep tabs on hospitalized inmates to make sure they’re discharged and returned to state care as soon as possible. The contractor, Permedion, is paid $1 million a year but state officials estimate $24 million a year in costs are avoided. The state is also renegotiating its contract with Ohio State University Medical Center, which currently costs about $65 million a year, or about a third of the entire prison health care budget.

Reducing care not an option

DRC occasionally seeks court permission to release inmates with significant or terminal medical conditions. Since late 2006, the Corrections Medical Center has had 35 medical judicial releases and is requesting six more.

But state law and DRC policy bars medical release for anyone serving a death sentence or life without parole or a sentence for murder or was convicted as a violent sexual predator.

On the second floor of the Corrections Medical Center, in rooms off of the dimly lit hallway, is the end of the line for bedridden and wheelchair bound inmates, many of whom are not eligible for a medical release and are too infirm to live in the general prison population.

“Nurse?” a reedy voice calls out. “I need a nurse.”

The smell of a soiled bed is unmistakable.

A few doors down, a man speaks to his roommate through a trachea with a robotic computerized voice.

Across the hall from him, a scrawny, wizened old man is so frail that he needs help putting on a jacket. His roommate sits in a wheelchair, staring at the concrete block wall.

In their younger years, these men killed, raped and preyed on others. But these days they are debilitated by illness, injury and old age and are living out their final days in what is essentially an acute-care nursing home within the state prison system.

“This is the realization of why we are spending so much on medical care. You come here and see the gravity of it. We have a lot of sick inmates. That is the bottom line,” Hudson said. “Even though they’re in the physical or mental state that they’re in, we can’t release them by law. We have no other option other than to care for them.”

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