The field of correctional health care is a well-kept secret. Few freshman medical school classes even know this is one of the career opportunities that exists for them after residency. So how does a medical director go about recruiting? Who and what does he or she look for? This is a real question in many state and federal facilities. There are many valid and meaningful criteria that make correctional medicine a very competitive career choice.
Factors such as work satisfaction, reasonable hours, salary, benefits, job security and ability to contribute to public health service were rated very favorably in comparison with the community positions. This change in the position of correctional medicine is due to many factors, not the least of which is the increasing pressure in the community brought on by dwindling reimbursement, increased overhead cost, paperwork for insurances, juggling of individual insurance mandated formulary, prior authorization, cost-prohibitive electronic medical records (EMR) implementation and increasing demands of running a business - all of which contribute to decreased family time. There are also the efforts of organizations such as the American Correctional Association, which have helped bring the importance of correctional medicine to the attention of the administration in correctional facilities. Now that the playing field for physician recruitment has been leveled by marketplace and internal correctional insights, how does one approach this problem?
Offenders have been receiving medical care for many years, so why focus attention on the correctional health care field now? When a 1997 Supreme Court decision established a fundamental right and access to health care for all offenders, the field started to evolve with standards that were developed for care provided to offenders. Standards focused on similar care that paralleled community care. Correctional health care includes medical, mental health and dental care.
There have been many conversations among correctional health professionals regarding health care provided to prisoners - politically, socially, personally and philosophically. However, it is neither discussed with academia nor brought forth for discussion of what constitutes prison health with the community. The reason? Stigma. Not for correctional health professionals, but for the general medical profession. As a result, there are many misconceptions about the field.
Increasing Costs of Practicing Medicine
There is revolution going on, albeit a quiet one, in the medical field. The cost of medical care is increasing. Reimbursements from insurance and government-funded programs are decreasing. Overhead is escalating. The federal government is mandating that EMR be implemented by a certain date, while the expense of EMR is cost-prohibitive for small, private practices. There is increasing scrutiny of medical errors. A change in insurance contracts and justification for prior approval is increasing the cost of staff and thereby decreasing returns, causing medical providers to consider other options. Medicare and Medicaid set the prices of what is appropriate reimbursement for doctors, and year after year, providers have seen a decrease in reimbursement by the government agencies. Share of collection from patients has also jumped without any hope of collecting for the service provided.
In recent years, there has been a trend in hospitals buying up medical practices. For the first time, the number of medical practices that were physician-owned has dropped below 50 percent. A March 17, 2012, article in The Wall Street Journal cited numbers that are even more grim than before: Only one-third of practices are now physicianowned. Time is on our side in recruiting physicians. Correctional medicine provides a better environment for the practicing physician because there are no hassles of prior approval, collection of receipts or a contractual quagmire of insurance contracts, yet there is flexibility and good benefits. We as correctional staff should stand up, speak up and wave a banner to community medical providers of the benefits that correctional health care provides. Financial stability that was once a dream to strive for in private practice is harder to achieve now with all the factors cited above. It is time for correctional health care to be in the forefront of recruiting providers.
Benefits of Working in Correctional Health Care
The stigma of being seen as a prison doctor, with its concept of underachievement, is something that is not supported by the fact that the practice of healing arts in a prison exists and is alive. It is hard to understand why this stigma exists. The primary care physician in the prison provides comparable care without some of the restrictions seen by community providers. The challenges of the environment should not diminish the worth of the provider.
How do we dispel the myth that prison doctors are not all they could be? We need to educate our colleagues. Tell them the challenges, as well as the thrills, of taking care of underserved populations while being paid competitively. There is no agony about overhead cost, no malpractice to contend with, no concern of cramming patients into fiveminute appointment slots, no insurance paperwork, no prior authorization, no time spent on looking at all those formulary specifics for a particular insurance coverage. And it all comes with a safe environment in which to work. In corrections, security staff is attuned to the safety and protection of staff.
Serving the Public
Public health is a big part of the mission of corrections. Addressing the public health issue typically gets ignored in small communities. Much of the population seen in the prison setting is dependent on public support of health care in the community. Correctional staff are in a position to address all of their health issues in a structured environment. This is a great public service. The lifestyle of men that populate prisons have many, if not all, of the risk factors for hepatitis B, hepatitis C, HIV, STDs and tuberculosis. These disorders can significantly impact the health of a community if they are not diagnosed, the disease process managed and the patient educated as to the infectious nature of his or her disease. Often the only time some of these offenders see a doctor is when they are incarcerated.
Prison is sometimes chosen as an option by the courts to bring a favorable intervention into an offender's life style. The prison is often asked to provide the structure, education and pharmacological support that allow these individuals a chance to have a productive existence. General medicine and psychiatry work much better when patients are not using illegal drugs, are eating good food, sleeping well and participating in the programming provided by the staff. Prison, sadly, may be their only chance to get back on their feet. Correctional health care staff are a big part of that transition.
A significant percentage of prison populations have medical and psychiatric problems. Correctional physicians provide medical care ranging from simple ailments to chronic medical problems. Providers attend to serious problems like coronary artery disease, seizures, psychosis, suicide monitoring, detoxifications from addictions and a multitude of acute problems. End-of-life and chronic pain management are also prevalent issues in this setting. Aging prison populations have added another dimension of managing dementia.
Traumatic brain injuries (TBI) are also a burden on resources. There has been an increase of veterans returning from foreign wars with a multitude of ailments, including, but not limited to, TBI, post-traumatic stress disorder (PTSD) and major depression. Patients with mental illness are entering prison systems at a rate than was unimaginable 10 to 15 years ago. Management of acute psychosis and suicide monitoring is a daily occurrence.
Dealing With the Business of Medicine
Demands of time and energy for the management of patients may seem to be elevated, yet they do not compare to the demands of running a private practice. The days of a doctor being able to juggle involvement in his or her practice may be over. Managed care is in an increasingly difficult situation, as reimbursement for services is dependent on the quality of the service provided, the documentation provided and the number of patients seen. The capacity to be able to spend quality time with family or friends is diminished by the performance expectations of the business of medicine.
After trying to make a living practicing medicine, it is hard to make a single decision without the business side of it coming into play. The pressures of an industry-wide strategy where one must satisfy a third party to get paid, coupled with government and insurance scrutiny of health care decisions and resource management, contribute to an environment where it is considerably harder to make a living than was indicated in medical school. The work environment is very different in corrections: no insurance claims to deal with, no malpractice insurance, and no distant medical insurance plans. The ability to go to work to simply practice medicine in correctional health care is often one of the reasons doctors stay in correctional medicine.
Increasing Numbers in Correctional Health Care
The silent revolution in the medical arena has at least shone a light on the correctional field. At the University of Massachusetts Medical School in 2009, 22 of 150 new students chose the correctional health care clerkship as their first choice - more than double the typical response.1 Students are also looking for employers who offer flexible work and a steady paycheck. More and more students are electing to do their clerkship in Iowa. Many medical, physician assistant, nursing and advance registered nurse practitioner students rotate at the Iowa Medical and Classification Center for their final year. This is also a great recruiting tool for future providers. Correctional health care programs can also qualify for National Public Health Service for underserved areas for loan reimbursement.
In correctional medicine, there are challenges equal to any clinical or ER setting, a stable patient population, competitive reimbursement, flexible and reasonable hours and a chance to really make a difference in someone's life that is probably not equaled anywhere else in modern medical practice. There are many creative men and women who are proud to be a part of correctional health care. They are contributing to an effort by states to address a real and growing problem. If we are not going to leave any patient behind as we embrace universal health care, how do we shore the 10 to 15 percent of the population that consumes the greatest portion of the resources? This is done by taking advantage of the opportunity afforded by prisons to identify and treat the chronic medical disorders like HIV, hypertension, COPD, dyslipidemia, schizophrenia, major depression, PTSD and other personality disorders during their time in a structured setting of a correctional world.
The rewards of those providers who accept the challenge is one of the best-kept secrets in medical practice. The challenges of working out lifestyle choices and medical decisions with this group of patients can be a real chance for personal development for both doctor and patient. The opportunity to monitor medical interventions is unequalled. But to many providers, the real advantage is in the opportunity to be a doctor without being owned by a practice. The benefits include personal satisfaction; compensation while providing care that is equivalent to community accepted standards without the hassles of malpractice insurance, overhead cost or formulary restrictions by third parties; generous benefits and retirement programs; freedom from the whims of insurance and Medicare restrictions; and unparalleled job stability. Correctional health care should be on every doctor's list of career choices.
1 Kavilanz, Panja B.Dec. 27, 2009. Jailhouse docs choose inmates over insurance. CNNMoney.
Hartaos Deol, D.O., Ph.D., is the health services administrator for the Iowa Department of Corrections. Ed O'Brien, D.O., is a staff physician at the Iowa Medical and Classification Center.