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Making managed care principles work in the correctional setting.

Correctional health care delivery systems have been viewed by some as the original managed care setting, in the sense that there is a fixed budgeted amount of funds for the provision of health care for a defined patient population, regardless of the magnitude of health needs. Correctional health providers always have had to make decisions and prioritize medical services based on a budget. However, this alone is not "managing" care as it is being promoted today.

Although the definition of managed care may vary, there appears to be an underlying theme: Managed care is a health care delivery system in which costs, accessibility, quality and outcomes of care across a continuum of health services are tightly regulated using various rules, guidelines and oversight methods.

With this explanation in mind, the existing operations of a particular prison health delivery system can be examined and adjusted, utilizing as tools the following elements put forth by proponents of managed care:

* cost containment measures;

* access and utilization control:

* standards of care, outcome assessment and continuous quality improvement (CQI);

* provider and patient education; and

* management information systems (MIS).

Cost Containment Measures

When developing cost containment measures, administrators will need to consider a number of questions. Have all behaviors and activities (i.e., cost drivers) that generate unnecessary costs been identified at your facility? What corrective policies and measures can be implemented? For example, within the Massachusetts Department of Corrections (MDOC) health delivery system, lengthy hospital stays, numerous offsite secondary care referrals along with the associated transportation requirements were generating excessive costs. The MDOC subsequently privatized its delivery system and implemented a strong primary care system to bring those costs Under control.

Administrators also will need to make sure that controls are put in place that assign responsibility and accountability to specific individuals ("gatekeepers") for keeping costs down. For instance, it is well-known that medication is a major expense in health care delivery. A formulary of drugs approved for use in your institution must be instituted as a first step in controlling costs. Next, adherence to this approved list of drugs must be communicated to all health care providers involved in prescribing medications. The final step is to place a gatekeeper/physician responsible for approving or disapproving orders for any medications that are not included in your formulary. Updating of the formulary should be the responsibility of the pharmacy and therapeutics committee or the responsible physician.

Access and Utilization Control

Although inmates should have ready access to health care, how and when health services are used must be controlled. For example, in a managed care system, it is preferable that a patient with chronically infected teeth and gums be given increased access through frequent and regularly scheduled appointments. Patients should be treated in a manner that prioritizes the care rendered--from the most acute to least urgent. In this manner, savings can be realized while the quality of care is improved by preventing a moderate dental need from escalating into a more costly and debilitating problem requiring specialty care, emergency care or even hospitalization. The same situation would apply to patients with asthma or most other health conditions.

Evaluating Your Facility

When evaluating your facility in terms of standards of care, outcome assessment and CQI, the following questions should be answered: Are there written clinical practice guidelines in place that detail the appropriate activity for each category of health provider for the management of patients in the most frequently diagnosed disease categories? Is there a committee established that reviews outcomes of patient management? Are poor outcomes--such as misdiagnosis, mismanagement, poor follow-up and high rates of infection--a problem at your facility? Is there a mechanism in place for monitoring both quality of care and efficiency of operation on a continuing basis?

Educational Training

Staff and providers will need to be given training courses and seminars aimed at increasing clinical skills (which can decrease costly referrals to specialists), eliminating certain tests and other unnecessary procedures, avoiding repetition, reducing liability risks, increasing productivity and containing costs. Administrators also will need to ensure that programs are in place to educate patients about healthy lifestyles--that is, videos and brochures on nutrition, smoking cessation, oral health, chronic diseases and HIV.

Management Information Systems

Another key element in managed care is an efficient, automated management information system. To evaluate the system already in place, administrators will need to determine the following: Is patient scheduling and recall performed electronically? Can the activities of physicians and other health care professionals be monitored by computer (i.e., productivity, treatment outcomes, referral patterns, drugs prescribed, procedures performed and tests ordered)? Can patient records be stored and transmitted electronically?


A survey conducted in February 1993 by Corrections Compendium indicated that health care costs averaged $4,295.65 per inmate, compared to $1,130 in 1985.

To rein in these costs, federal, state and local governments are exploring new ways to reduce spending. Increasingly, they are turning to privatization as a solution. Private contractors for inmate health services are providing quality health care while remaining financially solvent by utilizing the principles of managed care. To remain competitive with private delivery systems, administrators in government-run correctional health systems will need to devise a proactive managed care plan, which may lead to structural reorganization and increased individual accountability.


Anno, Jaye. 1991. Prison health care guidelines for the management of an adequate delivery system. U.S. Department of Justice (NIC).

Crawford, Cheryl A.1994. Health care needs in corrections: NIJ responds. National Institute of Justice Journal (November).

Findeiss, J. Clifford. 1993. Massachusetts statewide privatization for medical and mental health services. Corrections Compendium (May).

Goldstein, George S.1992. Defining managed health care. HMO magazine (March/April).

Heinze, Joseph and Eric Rehorst. 1994. Dental triage systems: a key to prioritizing patients. CorrectCare (December).

Survey on health care costs. 1993. Corrections Compendium (May).

Theola Douglas, D.D.S., M.B.A., an oral and maxillofacial surgeon, is an assistant professor in oral diagnosis and radiology at Howard University's College of Dentistry. Lynette Mundey, M.D., treasurer of the American Correctional Health Services Association (ACHSA), is the bureau chief of clinical services for the D.C. Commission of Public Health in Washington, D.C.
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Author:Douglas, Theola; Mundey, Lynette
Publication:Corrections Today
Date:Oct 1, 1995
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