Joel Blackburn believes his patients require only the medical essentials.
“We don’t have to give them a sleeping pill like they’d take at home,” Blackburn said.
He also doesn’t prescribe Viagra to his patients at the Boone County Jail. “And believe me,” he said, “they ask for it.”
In 2004, Boone County spent almost $350,000 on medical costs for inmates at the county jail — almost $80,000 over budget. Because of excessive hospital costs, the jail’s medical expenses were over budget for the third year in a row. In April of that year, the county hired a new medical director in an attempt to remedy the jail’s ongoing medical situation. That person was Blackburn, an internal medicine specialist.
Approximately one year after Blackburn’s hiring, medical expenses are under control for the first time in years, said County Auditor June Pitchford. Even though hospital costs could not be fully remedied in 2004, costs are now about $35,000 to date — $15,000 under budget and about $71,000 less than the total hospital costs for 2004. Medication costs to date have been about $8,000 for each of the past six months, compared to about $12,200 a month in 2004. And Pitchford said she credits Blackburn with the changes.
Blackburn’s tenure with the jail is not his first time treating inmates. He previously served for a year as a prison physician at Moberly Correctional Center. Blackburn is responsible for the medical needs of about 200 inmates, as well as the related costs. Part of his contract even requires him to reduce the jail’s hospital expenses.
“When I started, there was a lot of money being wasted on medications and on inmates being sent out to the hospital,” he said.
The jail needed new protocols to control the number of inmates sent to hospitals, which Blackburn and his staff addressed by creating treatment plans for various ailments, providing nurses with guidelines for determining what type of medical care is necessary for each situation.
“We didn’t have a lot of protocols in the past,” said Heidi Fussner, a nurse at the jail. “We called physicians for just about everything.”
Protocols help in legal liability issues since they clearly identify what medical procedures are performed in examining patients, Blackburn said.
“It puts us at risk for malpractice without any sort of protocol,” he said. “That is why following a national standard helps.”
Because of the protocol, the staff will only send inmates to the hospital who require more medical attention than the jail can provide, Fussner said. “We are more selective about who leaves now.”
Improved on-site medical care has contributed to a significant decrease in medical costs, said Sheriff Dwayne Carey.
As an example, Carey said an inmate with chest pains would have immediately been sent to the hospital, but now the nursing staff can determine if the pain is serious or not.
Many other kinds of basic medical care that previously required an inmate to visit the emergency room can be done on-site, Blackburn said.
“For one thing, if they get a laceration or cut, I have suture material,” he said. “I actually go to the jail and sew them up myself rather than sending them to the emergency room like before.”
The staff tries to keep hospital visits at a minimum because of the cost of sending an inmate to the emergency room as well as the security risk, Blackburn said.
In such situations, at least a single guard must remain on-site for the duration of an inmate’s stay at any hospital for security purposes, Pitchford said. The county has to spend a lot on overtime pay each time it needs to provide security for an inmate’s visit to the emergency room, she said.
The staff has also been able to reduce the costs of medicine by using cheaper medications that work in a similar fashion to the more expensive medications that other doctors may have prescribed to inmates, Blackburn said.
Before Blackburn arrived, any prescription presented by an inmate was honored, Fussner said. The previous policy cost more both because of the expense of buying newer medications as well as making individual purchases through the pharmacies, she said.
The changes weren’t welcomed by inmates, Blackburn said.
“Many of them threatened lawsuits,” he said. “And I still get threatened with lawsuits every time I go out there.”
The bargaining table
State law does not require counties to pay for inmates’ medical expenses. Because inmates needed to pay their own medical care, the Boone County Jail’s administration sent any medical bills it received back to the respective providers before 2002, asking them to bill the inmate directly, Blackburn said.
The payment situation often left hospitals footing the bill, since most inmates were incapable of paying their bills, Pitchford said. The situation resulted in deteriorating relationships with the medical community, prompting former Sheriff Ted Boehm to start sending all medical bills to the Boone County Commission for payment in 2002 and increasing the jail’s medical costs drastically as a result, she said.
“The annual appropriation was quickly exhausted,” she said. “We very quickly noticed that we had a problem on our hands, and that’s when all the work began a few years ago to negotiate new agreements.”
In January 2003, Boehm attempted to remedy the payment situation. He lobbied the county commission for a partial reimbursement policy for inmate medical bills, prompting commissioners to negotiate new agreements in 2004 with the jail’s major medical providers: Boone Hospital Center, Missouri Medical Affiliates LLC and MU Health Care.
Under the new agreements, the county would pay a percentage of an inmate’s medical bill roughly equivalent to the amount Medicare or Medicaid would pay, Pitchford said. The new agreements would allow medical providers to receive some reimbursement for their work rather than none at all.
The new terms did not please some of the jail’s medical providers, Blackburn said, especially specialists used frequently by the jail.
“Some of them just cut the umbilical cord and ran, so we don’t have their services anymore,” he said.
While medical costs have remained relatively low for most of this year, Pitchford said the possibility of unforeseen expenses due to some sort of expensive medical problem always exists.
The medical staff is trying to only provide for the inmates’ medical necessities, because the medical director is not only responsible for the health of the inmates, but also the cost of caring for them, Blackburn said.
“The standards for jail are not the standards for the street,” he said. “It’s just a given fact that they don’t have to be. It’s what we have to do — we have to provide medical necessity for the inmate.”
Inmates have slowly been adjusting to the changes in the jail as well, Fussner said.
“At first there was some resistance,” she said. “But the inmates are finding out that their health has not drastically changed, and they are beginning to accept the changes.”
The staff is still trying to find new ways to cut costs, Blackburn said, in addition to finding someone to fill a vacant full-time nurse position. As cost-cutting efforts continue, Blackburn recognizes that “you get to the point where you run a fine line between not sending a person to the hospital and running into a liability issue.”