Officials in Pueblo County, Colo., know of at least two inmates who were released from the county jail and committed crimes to get back in--not your average course of action for offenders who, you'd think, would prefer freedom over incarceration.  But, healthcare in the real world can be hard to come by and these men wanted the same services they had received inside the jail.  So, they reoffended. 

It's a strange testament to the county's correctional healthcare system, but proof that it's doing something right in terms of the medical care it provides to its inmates.  The jail's healthcare system didn't always run so smoothly, though.  Just ask Rita DeHerrera who was recruited by Pueblo County in 2002 to revamp the jail's healthcare system and help drive it into efficiency.

DeHerrera, CEO of Management Team Solutions, a company that works with managed care systems, used her experience in dealing with Medicaid to help create and advocate for a bill that changed the face of jail healthcare in Colorado.  When it became law in 2003, Senate Bill 03-141 opened the door to substantial healthcare cost savings for all county jails, not just Pueblo's, where DeHerrera, with no experience in correctional healthcare, conducted an analysis of the jail's system.

She was shocked by what she discovered.

Counties Kept in the Dark

"We were amazed that this population was getting full care and treatment that the county taxpayers were paying for and there was no management of medical costs within the system," said DeHerrera, who currently serves as the jail's healthcare administrator.  "It was like they were living in the old age when healthcare paid providers pretty much what they asked for."

The jail had been paying hospitals 75 percent of charges for each inmate visit, with between 25 and 30 offenders going to the emergency room each month.  To some other providers, the county had been paying in full for billed charges.  These rates were extremely high, according to DeHerrera. 

But the county didn't know any better.

"I've never done jails, but I go in there and I see a system of taxpayers paying these high costs and the county has no clue that [the providers] are basically overcharging for the services compared to what they get in the marketplace," DeHerrera said.  "You have the medical providers taking advantage of the ignorance of the county jail system.  They didn't know what was a good rate."
Making an Argument for Medicaid

DeHerrera recognized an immediate correlation between the indigent population that it serves and inmates, who lose their right to Medicaid and other benefits when they are incarcerated, which often leaves them "truly indigent," said DeHerrera, who has dealt with Medicaid in the past.

With these two groups being equal in DeHerrera eyes, she saw no reason why county jails should not be paying Medicaid rates to hospitals and other providers.  At 35 percent, the Medicaid rates would save the county almost half of what it was paying to hospitals.

"I advised the county attorney to renegotiate the hospital contracts because they were paying way too much for a patient base that was indigent," said DeHerrera, who struck a deal with some area providers that allowed the county to pay Medicaid rates plus 10 percent.  "I had a number of providers that agreed to that, it was just a matter of communication.  But the hospitals wouldn't budge." 

The hospitals, which were content with their contracts, were a major obstacle for DeHerrera in her quest to lighten the county's financial burden.  Without their cooperation, she turned to the state Legislature for help.

Getting the State Legislature's Support

"Legislators are always looking for good ideas.  What we do up here is write legislation that addresses issues that impact local governments and healthcare is one of the major [issues] in our whole state," said Sen. Abel Tapia (D-Pueblo). 

When DeHerrera explained to Tapia that the jail's healthcare system lacked management and structure and that the hospitals were charging the county unfair rates, he became aware of an issue with a statewide scope.

"Her sense was that the private hospitals were taking liberties in terms of the [rates] that they were charging the inmates and she felt that we could actually do something about it, not only in Pueblo, but also statewide," Tapia said.  "It hit all the hot buttons that would get me to want to carry such legislation."

With Tapia and some other legislators to sponsor the bill, DeHerrera was a step closer to getting the hospitals to lower their rates for county jails.  But when she received the first draft of the bill, it was missing a something.

Hospitals Give Counties a Hard Time

"I looked at it and I was very upset because the meat of the bill about the Medicaid reimbursement being charged was taken out," DeHerrera said.  "The political pressure was pretty strong and the hospitals didn't want this mandate."

The language that had been removed concerning the hospitals and the Medicaid rates had been replaced with wording that would enable counties to use the Colorado Mental Health Institute at Pueblo (CMHIP), a state facility which provides care to state Department of Corrections and federal inmates.  It is required, by law, to charge at cost only. 

Gaining access to CMHIP was beneficial to the counties because it not only gave them the option to send inmates to the facility, but also, because CMHIP has security services, the counties do not have to send their own staff to guard inmates like they would for a private hospital.

But, while DeHerrera was pleased that the bill opened CMHIP's doors to the counties, she was not willing to let the hospitals off the hook.  Rather than backing down, she appealed to another organization, which had some clout.

"We had to bypass local hospitals and go directly to the Colorado Hospital Association," DeHerrera said.  "They supported the bill."

CHA's endorsement was enough to get the provision requiring hospitals to honor Medicaid reimbursement rates when dealing with the county jails back in the bill.  This support helped to set up its unanimous passage in both the state House and Senate.

"Everyone has a county jail and a city jail and they all have issues about healthcare costs and most all correctional facilities have an issue in terms of [how] that cost is [increasing] much faster than our revenues," said Tapia. "[The legislators] looked at [the bill] as a solution to their counties' [jail healthcare] problems."

As the law stands today, hospitals are required to charge Medicaid rates to the counties for prisoners and the CMHIP is accessible to them, too, for medical, surgical and mental health services.

"The nice thing was [that] we went ahead and left [CMHIP] in [the bill] along with the mandate for Medicaid reimbursement rates," DeHerrera said. 

Having two options gave jails the opportunity to compare fees and see whether sending an inmate to a private hospital or CMHIP would be more cost-effective for the county, DeHerrera said. 

Inmate Pay Back

While the crux of the bill revolved around Medicaid rates and CMHIP, there are other aspects of it that now also help counties save healthcare money.  For one, it makes it easier to recover money from inmates for the medical services they received while incarcerated, a process that was previously hindered by cumbersome laws, according to DeHerrera.

The law serves streamlining judicial procedures for counties to recoup these funds, which is only fair, according to DeHerrera. 

"If [the offender] gets a job, they should have to pay [the county] back because anybody else would have to pay for healthcare services [who] didn't have insurance," she said.

With simpler procedures in place to gather money from inmates for healthcare services, the load was lightened even more for all counties in terms of healthcare expenses.  But, in Pueblo County, DeHerrera went even further to reduce their expenditures.

Shuffling Staff

"Within probably 60 days [of first working for the Pueblo County Jail] we reduced their healthcare costs by 22 percent and that was just by putting a medical management system in place," DeHerrera said.  

Staffing was one of the first areas she tackled and, right away, DeHerrera made a decision to change the types of healthcare professionals who were being employed at the jail.

"We decided to staff 24-7 with EMTs and paramedics, which are not as expensive as RN's, but they have the skills needed to provide emergent care services [and] immediate care," DeHerrera said.  "We put a provider on-call system in place as their resource.  Physician's assistants, nurse practitioners, EMTs [all] have access to [the on-call provider].  They stabilize the inmate and call [them].  If need be, the provider will come on site or instruct the EMT."

By implementing this new on-call provider system, the number of inmates visiting emergency rooms dropped from between 25 and 30 each month to only one or two every couple of months, according to DeHerrera.  Less frequent inmate visits to the ER, alone, were a cost savings to the county.

Fighting for Better Healthcare in the Future

These changes served to cut the jail's healthcare expenditures from $1.2 million per year before she came on board to around $800,000.  And, during her two years there, DeHerrera has kept the budget under a million dollars.

With the jail's financial situation improved, DeHerrera next hopes to tackle the issue of continuity of care: making sure that inmates are continue to receive the treatment they need in the community rather than reoffending for the sake of getting healthcare.

According to DeHerrera, progress is already being made in that direction, with the creation of a community well-being program that kicked off this past February with the goal of helping ex-offenders to obtain healthcare and education and develop work skills.

The ultimate goal is to keep people out of jail, DeHerrera said.  But if they are incarcerated and need healthcare, it will come at far less of a cost to the county now, as a result of her efforts.

Resources:

To contact DeHerrera, call (719) 250-3243

To contact Sen. Tapia, call (719) 671-3311