CONCORD, NH - Health-care costs for the Department of Corrections ran $1.63 million over budget this year. Prison officials attributed that to a high number of inmate emergencies and extraordinary medical expenses, such as cancer care, that require treatment outside the prison.

Some lawmakers said they're weary of responding to the corrections department, which consistently exceeds its annual medical budget and turns to the Legislature for end-of-the-year appropriations. Lawmakers on the joint fiscal committee usually grant those requests, accepting prison health-care as an unpredictable but mandatory expense. But some said it's time for more scrutiny.

Senate Majority Leader Bob Clegg thinks more could be done to control inmate medical expenses and prevent the need for additional appropriations. "I think it's a huge issue," said Clegg, a Hudson Republican.

Clegg, a member of the fiscal committee, questioned whether all specialty treatments were necessary. He wants to know if the prison system could make more frequent use of a law allowing for inmates with extraordinary medical bills to be released from prison, provided they're not considered a threat to society.

"We've had the medical community from the prison system come in and tell us that they think it's their duty to make sure that if some guy's got less-than-perfect teeth while he's in there at state expense, they give him all-new dentures. There's been elective surgery performed because they want to make sure that when they get out of prison, they have every advantage possible," Clegg said. "A lot of people say, 'Wait a minute. I don't get that, and I haven't done anything bad to anyone.'"
 
Over the past five years, medical and dental expenses for the prison system have exceeded the amount budgeted by more than $26 million, or nearly 25 percent. In each of those years, corrections officials requested additional money from the Legislature; lawmakers on the fiscal committee granted the requests four times and told the prison to make up the difference internally in the other year (2003), according to records provided by the Department of Corrections and the Legislative Budget Assistant.

The fiscal committee approved the latest appropriation - $1.2 million transferred from the general fund, along with permission for the department to transfer another $427,000 internally to pay the rest of its medical bills - earlier this month, and the governor and Executive Council authorized the move yesterday.

That will allow the department to meet its medical expenses in the budget year that ends next Friday. The prison system began the year with $6.24 million for health care -part of a roughly $90 million overall budget for the corrections department - but finished with about $7.87 million in medical expenses. (The medical budget includes dental costs but not psychiatric care, which is covered by a separate appropriation.)

Prison officials said this year's deficit was caused by a high number of unpredictable and expensive conditions, including cardiac emergencies, cancer, cirrhosis and kidney failure. Thirty seven inmates had individual medical bills of $10,000 or more, including four whose expenses topped $100,000 apiece. That means less than 1.5 percent of the state's 2,600-plus inmates accounted for more than 20 percent of medical expenses.

Prison doctors and nurses provide in-house primary care for inmates, and the department also offers some specialties on location, such as eye care and podiatry. Other specialties and emergencies are treated outside the prison. Those procedures are ordered only when prison medical staff consider them necessary, and elective surgery for inmates is prohibited, said Jeff Lyons, a corrections spokesman.

Rep. Fred King, chairman of the fiscal committee, said he considers the prison medical requests to be inevitable but necessary. "The citizens of the state want people locked up if they do bad things, and they want them kept locked up,"said King, a Colebrook Republican.

The tough-on-crime movement of the 1980s brought longer prison sentences. King, a former state senator, has tried multiple times to introduce legislation that would reduce prison sentences for good behavior. Lawmakers have shown little support for the idea, he said. "I don't envision that would ever happen," he said.

Short of letting more inmates go, lawmakers need to understand that rising health-care expenses are the "nature of the game," King said.

Corrections Commissioner William Wrenn, who took office in December, said he has learned quickly that it can be difficult to predict and manage medical costs. Inmates are ineligible for federal health assistance provided through Medicare or Medicaid, so the state shoulders all of the financial burden, he said.

"It's a daunting task at times, because these inmates require medical care while they're in our custody and control," Wrenn said yesterday. "I don't have a crystal ball to see who's going to require certain procedures."

Wrenn said he is collaborating with Health and Human Services Commissioner John Stephen to examine ways to reduce costs. Among other possibilities, corrections officials are looking into buying a dialysis machine to treat kidney failure in-house. This year, the state spent $730,000 on dialysis for four inmates. The most severe case of kidney failure - an inmate who was sent to Oregon for treatment -cost New Hampshire more than $285,000. By comparison, the state's entire dialysis bill last year was $169,000, according to prison statistics.

When Wrenn appealed to the fiscal committee earlier this month, lawmakers granted the money unanimously but grumbled about it. Clegg and others asked to see details for the most expensive inmate treatments and questioned whether any might be candidates for release under the medical-parole law that passed two years ago. They also wanted to know why the department sent that inmate to Oregon and how that cost would have compared with in-state care, because a two-year-old law prevents New Hampshire hospitals from charging the state more than 110 percent of Medicare rates to treat inmates.

Wrenn and Bob Mullen, director of the prison's administration division, were unable to provide immediate answers at the meeting. Last week, the department sent the fiscal committee details on the most expensive inmates and an explanation of the medical-parole law. The response was helpful but fell short, Clegg said.

"The fiscal committee has always asked the same questions we're asking now, and it's very difficult to get the answers," Clegg said.

Prison officials told the Monitor this week that they could not provide a breakdown of the department's $7.87 million in medical expenses, aside from the explanation of the $1.7 million in extraordinary cases supplied to lawmakers.

All inmates receive a physical when they enter prison. Inmates over 65 get another checkup every year, while younger inmates get them every two or three years, depending on age, said Bob MacLeod, administrative director of medical services for the prison system. The department tries to keep costs in check in a variety of ways, from using generic prescription drugs to arranging emergency-care contracts with certain hospitals to obtain better rates than the maximum set by state law, he said.

That law, which caps the hospital rates at 110 percent of the cost that would be allowed by Medicare, covers emergency and inpatient care; it has saved the department more than $100,000 a year, prison officials said. But treatments such as dialysis are not capped, which is why the state sends some inmates to Oregon for treatment, MacLeod said. That state has an in-house dialysis machine and can provide the service at a lower rate than a New Hampshire hospital, even with transportation and other expenses, he said. The bill for the inmate sent to Oregon this year exceeded $285,000 because of serious infection and other complications.

That inmate, a 26-year-old who was serving time for attempted homicide, was paroled for non-medical reasons in March, and New Hampshire sent another inmate to Oregon for treatment, MacLeod said.

The medical-parole law allows the department to release inmates with high health-care bills, but the state uses it sparingly. The department continually looks for likely candidates and releases about one or two a year, MacLeod said.

Prison medical expenses have risen 33 percent in three years. That's partly a result of rapid increases in the cost of health care and partly a result of a swelling inmate population; the average number of state inmates grows about 2 to 4 percent a year in New Hampshire.

Inmates are also aging, meaning an increase in age-related health problems such as diabetes, high blood pressure and stroke, MacLeod said. As of July 1, 1996, 9.2 percent of state inmates were 51 years old or older. As of last June 30 - the most recent date for which prison age statistics were available - 15.8 percent of inmates were 49 or older.

Conditions that aren't tied to age are also on the rise, MacLeod said. About one in four prison inmates in New Hampshire has tested positive for hepatitis C, a liver disease often caused by substance abuse; that's roughly double the rate of three years ago, he said.