by David M. Reutter
With an increase in Georgia's prison population, the cost to provide medical care to prisoners has soared. Due to legislative budgetary restraints, the Georgia Department of Corrections (GDC) is finding it increasingly difficult to provide the required constitutional level of health care according to an August 2007 report by the Georgia Department of Audits and Accounts Performance Audit Operations (Auditor).
The report was a special examination of GDC's health care system, which follows a 2004 program evaluation by the Auditor's office. The audit report found that GDC's Office of Health Services (OHS) had "developed an extensive management control system to effectively manage all aspects of physical, mental, and dental health care." While problems are bound to exist in a complex system, the report concluded that "the quality of the inmate health care system is threatened by decreasing staffing levels that are a result of budget constraints."
The Auditor's 2007 report found the GDC had significantly reduced OHS's staff, which adversely impacted OHS's ability to manage all aspects of prisoner medical care. One effect of the staff reduction was that OHS no longer conducts annual physical health audits, which GDC had agreed to do as a result of the Auditor's last evaluation.
Rather than have OHS perform annual audits, the responsibility for scheduling audits rests with the Office of Investigation and Compliance.The result is that OHS is less involved in monitoring the findings and corrective actions related to health services. OHS staffers interviewed by the Auditor said there was no process to ensure they received the reports or were notified of issues arising from clinical audits.
The reduction in OHS staff has also affected executive mortality reviews of prisoner deaths. For the years 2005 and 2006, 233 prisoners died while in GDC custody (excluding executions). A mortality review process, according to national correctional standards, is necessary "to educate health care staff about trends in and causes of inmate deaths, and correct any identified deficiencies that may have contributed to the death."
OHS conducted mortality reviews on only 30 of those 233 deaths. GDC stated that it discontinued mortality reviews due to a 2005 ruling by the Ninth Circuit Court of Appeals that held physician peer reviews of prisoner deaths were discoverable in litigation. The Auditor noted, however, that only one of the 30 reviews occurred after the departure of OHS?s leadership staff, "suggesting that OHS staff turnover may also have contributed to the discontinuation of the executive mortality review process."
Additionally, OHS was unable to locate medical files for 86 of the 203 deaths not reviewed. After the Auditor identified this issue GDC was able to locate only 41 of the 86 files, and said it was making "concerted efforts" to find the other files. GDC stated it had developed a system "to identify, track, and locate files of deceased inmates."
GDC contracts with nationally-recognized correctional health care experts to review its medical care system. The Auditor said GDC had failed to address recommendations made by those experts; for example, that mortality reviews performed at the facilities where prisoners die be examined by OHS staff.
Turnover of OHS staff was also of great concern to the experts. One noted that virtually all of the leadership people he met in June 2005 had "either retired or moved on." The workload of the state medical director was seen as overburdening.
The experts also found issue with the prison system's grievance system, and noted that none of the 150 grievances filed by prisoners related to health care in a two-month period were deemed by prison officials to be valid. Corrections board member Tom Salter suggested that fact supported the proposition that health care for prisoners was adequate. The experts, however, observed that such a result makes "one suspect that the method of determining validity [of grievances] may in fact be biased."
As for the grievance process, it appears to have no other function than to label prisoners as complainers. Not only does the process appear to be biased, but GDC does not try to identify patterns in grievances related to deficiencies in physical, mental or dental health care. Additionally, the number of grievances entered into GDC's Offender Tracking Information System is significantly different from the number recorded as having been received by OHS.
To contain the costs of specialty appointments for various prisoner health services, GDC uses utilization management to review the appropriateness of requests for such services. Data over the past two years revealed an increasing backlog of pending requests and approved appointments. GDC blamed staff turnover and continuing changes in the network of outside health care providers for the backlog.
Lack of staffing was found by the Auditor to create a significant risk of litigation against GDC. In the dispensation of physical, mental and dental care by OHS, the staffing levels failed to increase with the prison system's population. Since 2005, GDC's population has increased 10.3 percent, from 44,276 prisoners to 48,922. This increase is expected to rise due to a change in parole rules related to release criteria.
In contrast, the budgeted number of GDC's full time employees has increased by only 3.2 percent for health care administration. Some disparities were evident in the staffing numbers. The number of physicians decreased by 4.4 percent, while the number of clinical practitioners increased 9.2 percent. Although mental health positions have increased 15 percent, OHS said it was still short 42 counselors, leaving 10 of 26 prisons understaffed to meet targeted counselor-to-prisoner ratios. As for dental care, GDC employs only one dentist for every 2,100 prisoners, which is well below its target ratio of one dentist to every 1,200 prisoners.
The financial resources budgeted to GDC were faulted by the Auditor for the department's health care deficiencies. GDC agreed, especially in terms of reductions in OHS staff. "I did cut my central office in half, but where the people need to be is out in the clinics," said GDC commissioner James Donald.
Lawmakers and the public clamor for more prisons, but fail to realize the fiscal drain on the public purse caused by incarcerating more people for longer periods of time. In the past year, 21,000 prisoners entered the GDC but only 18,000 were released. On average since 2003, GDC's cost of prisoner health care has increased 4.57 percent annually.
"My medical costs are going to go up $25 million this year to almost $200 million," said Donald. "This is the bare minimum to have a safe system." In all, GDC has requested an additional $103 million to cover the costs of the state's burgeoning prison system.
That sum may not be enough if the Auditor's projections hold up. Under those projections, the cost of prisoner medical care will experience an annual increase of 9 percent until 2011. It is expected that GDC's medical costs will rise to $278 million by that year, which is approximately $99 million higher than the amount expended in fiscal year 2006.
Overall, the Auditor found GDC was doing very well in terms of cost containment. One area that could save $1 million annually would be to increase the number of prison infirmary beds rather than paying hospitals an average daily cost of $3,681 for in-patient treatment.
Of great concern to the Auditor was the potential for inadequate funding of GDC's prisoner health care to eventually lead to federal court intervention, as occurred in California in 2005. Because litigation is expensive it should be avoided, the Auditor noted. Despite that being an obvious and recognized fact, more often than not legislators allocate funds to sources other than prison medical care, then point fingers at prison administrators once it's too late to remedy the situation.
Meanwhile, prisoners are the ones who pay the price through physical pain, deficient care or even death. That lesson has been repeatedly chronicled in these pages since PLN's inception.
The Auditor's August 2007 report, titled "Inmate Health Care" (Special Examination 07-06), is available on PLN's website.
Additional source: The Florida Times-Union
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