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Below is the HillCo client report from the House Corrections Committee and House Appropriations Subcommittee on Articles I, IV & V May 29 joint hearing.

The committees met in a joint hearing to consider the following interim charge:
 
Monitor the administration of the Correctional Managed Health Care (CMC) system and examine forecasts for short and long-term criminal justice populations and health care cost trends.
 
Laurie Molina, Manager, Legislative Budget Board Criminal Justice Data Analysis Team

  • Correctional population projections are released every year
  • Rep. Ruth Jones McClendon asked about incarceration population moving on a downward trend and the projection moving on an upward trend
    • The data uses actual data along with projections; projections released in June will likely be lower than the projections releases in January 2013
  • Chairman Sylvester Turner asked why projections are increased when trends show decline in population
    • Projections are based on the same data sets that are used year after year
  • Chairman Tan Parker asked for more information on how projections are determined
    • Will provide those variables and data sets
  • Parker asked what the most expensive disease is to treat in correctional health care
    • Question is better left for a different witness

 
John Newton, Legislative Budget Board Public Safety & Criminal Justice Team

  • CMC plan describes the level, type and variety of health care given to offenders
  • Health care is defined as medically mandatory or medically necessary; necessary is still important but not as important as mandatory
  • The University of Texas Medical Branch (UTMB) provides health services to approximately 119,000 offenders
  • Texas Tech provides care to around 31,000 offenders
  • Some care is outsourced
  • CMC funding is a total of the appropriation from TDCJ’s three funding strategies
    • For this biennium the total is approximately $963 million
  • McClendon asked if the state participated in the Medicaid expansion if costs would have decreased
    • TDCJ prisoners are not eligible for Medicaid funding currently; inmates held in hospitals outside of a secure facility could be Medicaid eligible
  • McClendon asked how many patients that would include
    • Hospital Galveston has around 70 and other hospitals average about 30-40 inmates per day
  • Will have an issue brief on that issue this interim regarding what other states are doing with federal dollars for CMC and how the current law translates to what can be done
  • Turner asked for the brief to include information regarding what laws could be changed in the state to offset some CMC costs with federal dollars
  • UTMB and Texas Tech also receive state reimbursement benefits of about $54 million per year for employees giving care to these inmates
  • Projected cost for this fiscal year are around $500 million which creates a shortfall of around $20 million
  • TDCJ is suggesting a three-fold approach to handle the shortfall
    • Moving $4 million from the pharmacy into the other strategies
    • Targeting funds in TDCJ budget to move into CMC
    • Asking for spend-forward authority which is included in a budget rider; these funds would need to be made up in a supplemental appropriation for FY15
  • Turner noted one hospital in Pecos County that could handle CMC said they would need Medicare-plus reimbursement; are any other hospitals receiving Medicare-plus
    • Eleven hospitals have been contracted to provide care at higher than 100% Medicare rate; TDCJ must request that LBB approve the higher reimbursement rate
  • Turner asked why Pecos County could not receive the higher rate
    • There must have been other hospitals in the area that would accept the Medicare rate
  • Turner asked who pays that higher rate; how much higher is it in dollars
    • It is absorbed by the state; would have to drill down into the data to get those numbers
  • Turner asked if other models are being studied to provide CMC; the current model may be outdated
    • The law allows TDCJ to contract with other hospitals
    • Parker noted that conversation took place last session and other models are being studied

 
Dr. Owen Murray, Vice President for Offender Health Services, UTMB

  • Had almost 4.3 million patient encounters last year; mostly nursing
  • Telemedicine has been significantly expanded in primary care and psychiatric delivery programs
  • Infrequent pay increases make it hard to retain physicians in a hyper-competitive market
  • Have not had a great deal of upgrade in EMR equipment; not very functional since last upgrade 8 years ago; other software and hardware needs to be upgraded as well
  • A new drug has been discussed for hepatitis-c treatment; very costly; currently paying around $25,000 per course of treatment, new drug would bring that to around $63,000; newer drugs will be out in 6-18 months that may not require other drugs to be used in tandem but they will be more costly
  • Rep. Larry Gonzales asked about the new hepatitis drug; it is 84 pills at about $750 per pill
    • That probably reflects UTMB 340b pricing; costs about $1,000 per pill outside the prison system
  • Turner asked what states are using that medicine
    • Not sure any are using it right now, it is very new but it has become the standard of care outside the prison system
  • McClendon asked if UTMB has attempted negotiations to get lower pricing
    • UTMB has a meeting scheduled with the manufacturer to do that very thing
  • Parker asked if historically, the penal system lags behind general standards of care
    • CMC does not immediately embrace the latest and greatest drugs
  • Parker asked how long a patent must be in place before a generic can be developed
    • Not sure; it is likely that other drugs will come out before the patent it up on the drug being discussed today
  • The prison system uses 91% generic which is higher than most health plans
  • The CMC adherence rate is just over 50% which is higher than outside the prison system
  • Parker asked if cost savings from offenders not taking their medication creates a higher cost down the road
    • Absolutely; cannot mandate medication compliance
  • A little under 10% of the population is over 55; they are 7-8 times more expensive than younger offenders
  • Chronic diseases have increased in asthma, bronchitis, cardiovascular disease, liver disease, renal disease
  • Parker asked why the spike in those chronic diseases
    • An aging population
  • Turner asked how much money could be saved from being able to draw down federal funds to help offset CMC costs
    • $120 million per year could possibly be saved from the hospitalization strategy
  • Gonzales noted that number can change very easily based on changes in the Affordable Care Act; the state could have to be constantly changing state law to conform to the federal law
  • Turner noted that is the same as changing the reimbursement rates to UTMB and Texas Tech which happens all the time
    • Brad Livingston Executive Director of TDCJ noted the number being assumed that could be saved from changing state law to draw down federal funds is variable; the hospitals being discussed may not even be categorized as hospitals but as prisons
  • Parker noted the potential savings is dependent upon the state adopting the Medicaid expansion and what happens to the state budget by doing so may not make it worth it
  • Turner noted that the system currently in place is becoming unmanageable; the discussion is about saving costs
  • The high cost/high utilizers are mainly 55 year olds and older with chronic disease; finding other ways to house these offenders and care for them is another idea for cost savings; Connecticut managed to move similar offenders into some type of nursing home
  • Parker noted it was surprising that the number of end-stage liver disease patients doubled from 2013-2014; what is being done to stop the spread of hepatitis-c within the system
    • Education is the main thing; intra-system transmission of HIV has significantly changed since educational and preventative programs have been put into place
  • Parker asked if the preventative tool is the best tool for cost containment
    • Yes; also ensuring continued treatment after release because many times recidivism brings them back into the system
  • Parker asked if the EMR needs are software or hardware based
    • Both, the system is just old and bogged down; the volume of material has weighed down the system
  • Rep. James White asked if inmates come into the system with chronic disease or if they develop the diseases within the system
    • Some of the older inmates are expected to have these diseases; currently, many more younger patients are coming in with complicated diseases than they did 10-20 years ago
  • White asked if money could be saved by taking a patient to a rural hospital rather than an urban hospital
    • The UTMB decision team will make a determination of what care is needed and where the best place would be to receive that treatment; sometimes it is less expensive to take patients to other hospitals and that decision is made by the medical staff
  • Parker asked why a policy of more aggressive enforcement of medication adherence is not adopted
    • Livingston replied, offenders retain the same rights as patients; have no authority to enforce a treatment plan unless the patient is a danger to himself or others; medications are enforced for mental health or psychiatric patients

 
Dr. Denise DeShields, Executive Medical Director, Texas Tech Correctional Managed Health Care

  • Turner asked if cases are occurring where inmates are not receiving the level of care because of associated costs or vacancies
    • Patients can be moved from system to system if care cannot be given within a certain system
  • Parker noted there may be a greater bang for the buck in addressing the vacancy issue by increasing pay for nurses and techs instead of the head physician
    • Some allied positions are very limited in the care they provide and if they do provide care they must be supervised by a RN or a physician
    • Murray noted nursing has to be the focus; mental health is another place where we could get the best bang for the buck

 
Brian McGiverin, Texas Civil Rights Project

  • The Texas prison system spent the final 20 years of the 20th century under federal supervision because of poor medical care
  • Discussed cases in which other states have been forced to take action in their prison system because of inadequate medical care
  • Spending per patient per day is far too low to take proper care of patients; prison populations are increasing but spending is staying the same and not accounting for inflation
  • The solution is a sentencing commission to determine if sentences are just and fair

 
Jennifer Carreon, Texas Criminal Justice Coalition

  • Women are not receiving adequate mental health treatment in TDCJ facilities
  • Younger people  in TJJD do not have as many problems receiving health care as those in TDCJ facilities
  • Committee should prioritize health care needs for the female and youthful prisoner populations
  • Geriatric prisoners pose minimal risk to the population of the state and should not be kept in institutions; they are only 4% of the TDCJ population but represent a far greater percentage of CMC costs

 
Jennifer Erschabek, Texas Inmate Families Association

  • Correctional officers fail to identify serious medical and mental issues
  • Timely access should be a standard; there must also be standards for prompt treatment and compliance with specialist’s recommendations
  • Because of a shortage in pharmacy stocks, many patients’ medications are substituted or not given at all
  • Sometimes the copay system causes inmates to refuse care
  • Recommendations:
    • Personnel training should include medical and disability training
    • Medical hospitals need to standardize standing orders that take into account the facilities patients will be returned to
    • Pharmacies should have inventory systems and actual inventory that allows them to meet inmates needs
    • The copay system needs to be repealed
    • There needs to be 24 hour medical staff at all units
  • Parker noted he believes the copay serves a purpose but agrees a healthy discussion should be had
  • Turner asked how much the copay system has generated since its inception
    • $2.5 million
  • Turner would also like to discuss the copay system