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| You Need a Medical Commissary in Your Facility! |
| By Jeffrey E. Keller MD |
| Published: 05/07/2012 |
When I was an undergraduate, before I switched to pre-med, I was an economics major. Maybe because of that training, when I look at jail medical practices, I tend to look at all of the costs of medical practice, not just the monetary costs. For example, the total cost of providing a medication to a patient in the jail includes the cost of the medication (of course), but it also includes the cost of the various people, like nurses, pharmacists, deputies and practitioners, who spend time creating the prescription. Thinking of costs in this way can change our perspective of what something “costs.”
Consider the case of the man with heartburn. We’ll call him “Jeffrey.” He doesn’t know it, but he is about to go to jail. Before Jeffrey goes to jail, if he wants to purchase something like ranitidine (Zantac) for his heartburn, he would go to a store and buy it. He doesn’t need to see a medical professional. He doesn’t need a prescription. In most places, he doesn’t even need to wait—convenience stores sell ranitidine 24/7. The monetary price Jeffrey will pay for 50 tablets of ranitidine at the store is around $7.00. The cost in terms of time is how long it takes him to run to the store. The total cost in time to the store to provide the ranitidine to Jeffrey is 30 seconds—how long it took the store clerk to ring up the sale. Now think of the same guy in jail. Jeffrey still has heartburn. Let’s say he still has money—now in his commissary account. He is still willing to buy ranitidine. But ranitidine is not on the jail commissary list. He can buy Ramen noodles or a Snickers bar, but not ranitidine. In order to get ranitidine, he has to put in a “Request for Medical Care” form. What happens now varies from jail to jail and prison to prison. I am going to present a typical jail scenario. The act of requesting non-emergent medical care costs Jeffrey $10.00. The form is then triaged by a nurse and Jeffrey is scheduled to see a practitioner. Since the clinics are crowded, the appointment is made for five days hence. In the meantime, he continues to have heartburn. On the scheduled day, he comes to the medical clinic. He waits, say, an hour in the waiting area. He then has vitals taken by a nurse. The practitioner, unsurprisingly, orders a prescription of ranitidine from the pharmacy for Jeffrey. The order is sent to the pharmacy and is delivered the next day. It is paid for from the jail medical budget. Total monetary cost to Jeffrey is $10.00. Total monetary cost of the prescription to the jail is around $6.00. Total price to everybody in time is, well, . . . a lot. Jeffrey had to wait five days. The jail medical staff had to process and triage the Request for Medical Services (10 minutes total?). A nurse and a practitioner had to see the patient in clinic (another 15 minutes total between the two?). A chart is generated, which then has to be filed (30minutes?). Deputies spent some time getting the patient to the clinic and back. The pharmacist spent time filling the prescription. The UPS/Fedex delivery service . . . well, you get the drift. It doesn’t matter if I am over-estimating the time. Just remember that we have to multiply whatever time figure we come up with by every request for an OTC [Over The Counter] product that is handled this way. Not just ranitidine, but also foot fungus cream, cough drops, rash cream, ibuprofen, acne cream, nasal spray and on and on. Why not put OTC medical items on the commissary and let inmates purchase them without having to go through the medical service? This actually seems to me like a no-brainer all the way around. Put the ranitidine on the jail medical commissary so that Jeffrey can purchase it without having to involve the medical staff. Jeffrey benefits by having much easier access to OTC products at a cheaper price. The medical staff benefits by not having to deal with requests for OTC products and having that much more time to spend with truly sick patients. I can hear you objecting! “We don’t charge inmates a fee to access medical clinic.” “Nurses can give inmates a week’s supply of OTCs; the inmate does not have to see the practitioner.” These questions miss the point that the main cost of making inmates go through “the system” to get OTC medications is time! The savings in time to nurses, for example, allows them to spend more time with truly sick and needy patients. If you do decide to set up a medical commissary system, here are a couple of items to consider. Indigency. What happens if Jeffrey has no money on his books? One way to deal with this is to allow indigent inmates to buy certain medical commissary items on credit (meaning that they “go into the hole” with their books—and if they ever get funds, the money is paid back). Another is for the jail just to absorb the cost of certain medical OTC products for indigent inmates—that is still cheaper than making them kite and go to clinic. The jail pays for the medication either way! Inappropriate OTC items. There are certain items that are available OTC at your local store that, in my opinion at least, should not be offered on a jail commissary. This includes any item that can be abused or that can cause serious harm when taken in overdose. I would include the following: dextromethorphan cough medicine, Benadryl and other first generation anti-histamines (though I would allow purchase of second generation OTC antihistamines, like Claritin), and Pseudoephedrine (used in meth production). No Ex-lax, of course! Too tempting to play practical jokes on your neighbors! Sometimes, inmates don’t like purchasing medical items off of commissary. They get it free if they go through the medical clinic. Time is not as important to them as it is for us. The answer to this question is to make purchasing OTC items off of commissary cheaper than going through medical. One way to do this is this: when an inmate comes through the medical clinic requesting, say, ranitidine; rather than order the item through the pharmacy, pull the item off of commissary and charge the inmate a small “urgent access fee.” The idea is that you want it to be cheaper and easier for inmates to purchase commissary items without bothering you. What items can be offered on a medical commissary? Remember that any OTC medical item you do not make available on the commissary can only be obtained by an inmate by going through the medical process. Here is one possible list:
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Oh well we already have a medical commisary but your article was pretty convincing! The one we have at our facility helped me with Acheter Viagra livraison express. I was pretty impressed and since then i have been in support of availability of one.
We have such a system and it works very well. There are specified limits on how many of each medication can be purchased at a time and we have a bypass system for when they come into cusotody with a headache on Saturday and commissary delivery isn't until Thursday. Medical services pays for a supply for the indigent inmates and their selection is only slightly more limited. You are so right, it's still cheaper than using the system to get the meds. The biggest problem we had instituting the system was the fear of loss of control on the part of the nursing staff. Correctional health care staff tend to be more controlling than we realize. We need to work on ourselves in that department. Our staff are very happy with the system now and there have been next to no problems in the 8 or so years we've been doing this in our 1700+ inmate system.
Great article Dr. Keller. Another cost to consider is the societal cost. Judge Dennis Challeen once said or wrote something to the effect, we take irresponsible people and make them more irresponsible. It is time we stop letting liability concerns run our systems. We need to get to the common sense approach of helping people learn how to be responsible for themselves. Certainly requiring people to prioritize their money so they take care of their needs first over their wants is a step in the right direction. If liability is the concern, it is likely lessened in Dr. Keller's model because the inmate is more responsible for themselves and has the control over the issue. When staff is involved there is more liability when they make a mistake and because the inmate it totally dependant upon them. Nice job Dr. Keller and thank you for the article.
In our facility the meds are strictly controlled by the nursing staff and the physician. We also have a staff psychiatrist who visits once a week and her meds are more often than not psychotropic in nature controlled by the federal government and state government. I think from my observations of sick call for 22 years in a county jail that medication dispensing is a necessary and mandated procedure. In New York the state is very specific on what meds are given by a physician, how they are controlled in a physical count including documentation to show when the meds were received, issued to the inmate and excess meds returned for credit when an inmate is discharged from the facility. The biggest issue you might encounter with any OTC med sold through the commissary is abuse. Obviously if you allow an inmate to purchase tylenol they could order as much as they wanted, then take the meds too often possibly causing stomach issues or worse. Much the same with other OTC medications that you have listed. The state told us only two medications can be held by an inmate. First is an inhaler for asthma patients and second nitroglycerin. The jail physician objected to the state about allowing inmates to keep nitroglycerin in their cells because they could take too many tablets thus endangering their health.