we knew they had records, but very often the prisons wouldn't send them and the states wouldn't work terribly hard. that should be something easy, especially with electronic records. >> debra? >> i want to say, we have in the district made progress in that area. i used to facilitate a federal partner's meeting. it was u.s. parole with our medical system here, which is unity health care. that's where all of our community health clinics are. and we sat down and we worked it out where all medical records -- because even when an inmate leaves the prison, they had trouble getting their record. so now all of the records follow them. they all go to unity. they're centrally located in unity. that's one progress we have made

in the district. >> and a one-sentence question. does the work they do in prison, does that count towards medicare? social security, medicare. >> no, it does not. there is a statutory prohibition -- >> wow. >> -- for medicare paying for any services provided behind bars. thst also a statutory provision that if you're on parole or probation, you cannot receive medicare benefit. on the medicaid side, there's something known as the inmate exception, which goes back again to the original finding of medicaid, which states if you're an inmate of a public institution as the exact statutory language, you cannot receive medicaid benefits at all. so again, one of the challenges going back to my comment about islands, and what i'm hearing you say is we need to figure out creatively how we build bridges to those islands. obviously, medical records is a part of it. thinking about bringing standards of care that medicaid brings is another part of it.

but at this point, we're all very much in the process of understanding it is not in our benefit to maintain those islands and the query becomes how do we build a bridge. >> thank you. >> if i can just -- i don't know whether this is something that you've had to grapple with, but one of the parts of your question was whether the work that was being done in prison could be counted as a quarter that would give you credit toward medicare credit eventually. >> and the answer is no. >> no? okay. >> hi. >> yes, sir? >> glen field, urban affairs advocate. debra, i heard you mention a 500-mile law. we constantly let this government get away with it. we have a law that's established

that any d.c. court offender or d.c. inmate couldn't be moved no more than 500 miles just to keep them with your family members, your loved ones. people in the district of columbia get locked up and have been traumatized. we have racial disparity going on here. any inmate -- like 3,500 return back into the city. 85% goes back within three years. so you celebrate. am i right, ms. rowe? you celebrate you made it past three years because it's a revolving door. i'm just asking steve and the panel, if you can agree with me, in the prison industrial industry, that they make a profit of this revolving door. when you don't get proper health care, as far as mental health care, when you have been

traumatized, post-traumatic stress disorder, you're coming back to prison. and the private industry makes a lot of money. they don't spend that money on health care, mental or physical. if you came into the prison system in the private industry and your pill cost $1,000 or 30 pills cost $600, you're not going to get that medication. you're not going to get the treatment you had in another facility or when you were at home. because 60% of any profits in the prison system as far as private are concerned is medical. a lot of people have been suffering, and they're going to suffer more. then they're allowed to come back out on the street. i'll point it out to steve, you know, mostly that we do need -- wouldn't you think we need some advocacy and some monitoring mainly at these private prisons and making sure that their

discharge plan starts earlier than eight months. doesn't mean the discharge plan you physically and mentally start getting these people back into health instead of sending them back out on the street, passing on diseases and thinking about new crimes can and things of that nature. because people take drugs because they've been traumatized in these prisons. so it creates a criminal. because they've been traumati traumatized. they don't know how to deal with these mental health illnesses. they have to supply their habit, and they're coming to get the citizens when they come home because they haven't been treated correctly. so you got worse off than what you were before you went in any system. i'd like the panel to chime in on any and all of that. thank you. >> i'd like to answer that question by framing slightly differently. we have proprietary companies that provide medicaid services through the united states. but those companies are

regulated. those companies have performance measures they need to meet contractually. the challenge with the correctional health system is by and large an unregulated industry. and if you have an unregulated industry, you have the opportunity for both the kind of human suffering that we heard debra and jackie describe, and the opportunity, sir, that i just heard you describe. i think, again, that's partly where being in this room in this building points to something we don't allow in any other sector of spending $8 billion on health care. do we allow it to be unregulated? do we allow it to operate without standards, without quality assurance, without any of the things that are statutorily required? so we now leave that under our federal system. we leave that up to states and counties to go ahead and regulate or not regulate as they may see fit. so what i'm hearing you describe is an underlying challenge that our federal system has allowed state localities to make their

own determinations as to what regulatory or quality assurance framework they're going to put down on correctional health. and in many jurisdictions, that's very nominal. >> okay. we have two folks at a microphone, and we really need to get to our second panel as well. so i would ask you to ask your question and we'll try to get it answered as expeditiously as possible. >> i just want -- my name is mary tierny. i'm a pediatrician. i had the privilege of getting a grant. we did outreach to youngsters coming out of the juvenile justice system. we got them on medicaid before they were -- or at least at the time they were discharged. we coached parents. we coached the youth. and the two people that really should be given credit is jane

adams in kansas who ran the program and the medicaid director who was full force behind this in dr. andy ellison, who at the time was the kansas medicaid director. he was magnificent in getting this. the recidivism rate was dropped by 50%, even in the highest risk youth. i'm sorry. i don't have a question, but i think it's a good model to think about. >> thanks, mary. >> can i go ahead? >> yes, linda. go right ahead. >> linda flowers, aarp public policy institute. so in my mind -- and thank you for this panel. it's just been tremendous and very insightful. i'm learning a lot. so it sounds like there's this cause shifting going on between the federal government while they're in there not paying for the things that people need, and then they get out -- if they're in a federal prison. then they're in a state responsibility, whether or not

there's a medicaid expansion or they become disabled or aged and can get on to medicaid that way. so i'm wondering if you could -- first, there needs to be more data about the amount of money that is not being spent on one end and how that translates into increakreecreased spending at t level once most of these people get out of prison. i think that could be a powerful tool for states to use to try to leverage better improvements while people are incarcerated in federal penitentiaries. and the other thing is i wonder if you can also try to figure out a way to cut the data by state to sort of show to a state the value of doing the medicaid expansion, that you're going to save a lot more money on other unanticipated costs because you've made a way for people to have a pathway to health care. but -- and also, i wonder if you

can talk about any best practices in states working with the federal government and states working together to have a better outcome while people are incarcerated and then when they transition out into a state -- into states. so i think you can beef this issue up a whole lot more than what i'm hearing. >> linda, those efforts are actually already under way. the federal bureau of prisons has just instigated a requirement for a standardized release in terms of doing substance use disorder evaluation. i think we're starting to see that kind of process come down. on the medicaid expansion side, i think the data that i gave you from washington state speaks very loudly to how there's a direct relationship between health care spending, recidivism, and criminal justice spending. so i don't think it's because of a lack of data that we haven't been able to make that push. i think, again, we have to realize that public health and public safety are intertwined and interconnected, and it does not serve anyone's interest let

alone the taxpayer to keep folks isolated on an island without the appropriate regulatory framework that we come to expect as part of our federal state and local partnership. so what i would say is the data is there, and we're in the process of the bop trying to implement exactly the kind of thing you're talking about. what we haven't done yet is we haven't made this conceptual leap. that's what we're all here today to talk about. we haven't made this conceptual leap that says we need to figure out how to build conceptual leap that has to build as many and as sturdy bridges between community and corrections as we can. >> okay. bob, last question. >> bob gris with the institute of social medicine and community health. i remember when senator wolford ran for senator from pennsylvania and made a big case about prisoners being one with of the only populations in the united states that had a right to health care. in fact, that was based on a supreme court decision. how does that precedent not

create the political power to implement the kinds of solutions that you're hinting at and haven't we learned anything from the tuskegee experiment? it seems like collecting data and not using it is a violation of -- of our civil rights. so where is that -- how does that fit into this problem? >> where are the lawyers? >> right. >> first, there are several questions and first i have to be a nerd here and correct, it's native americans under treaty and incarcerated individuals are the two individuals to whom health care is a right and not a privilege. in term of the gamble and the supreme court case. what the supreme court ruled was that the responsibility of a jurisdiction is to not be dlib letly indifferent to the health care needs of an individual. so, for example, if you had a

lawyer going back to your example, deborah, waiting a year to get a dental appointment. that dental appointment was made i wasn't deliberately indifferent to that person's need and i go back to regulatory frameworks, okay? that if again, how we do managed care within a community setting we require a certain number of days after which an appointment has to be made and we require a certain number of credentialing to provide care within the context. we don't do that in correctional health at this point and we're still on an island and that's the point that we'll say over and over again this afternoon. >> all right. i don't want to cut people off, but i do want to give us the benefit of our last two panel t panelists. jacqueline, deborah, thank you so much and if you'll be sticking around anyway maybe we'll find stray questions at the end of the q and a for the second panel. thank you so much. thank you. [ applause ]

>> and our nascar second panelists could come up, if i could. >> they're good. >> all right. ry are reconstituted panel wise. you've heard from steve rosenberg and the other panelists on my right, dr. sharon lewis medical director for the georgia department of corrections. she's a board-certified pediatrician and a nationally respected expert on quality assurance with more than 20 years of experience in health

care and managed care and right now she's responsible for delivering adequate and cost-efficient care to the inmates in the georgia correctional system. next to her is dr. asher turney who is the medical director for centurion of tennessee which is a joint venture of centene with which tennessee contracts to provide health care services for its correctional system. dr. turney is board certified in both urgent care and occupational medicine and he's got a special interest in health inequalities in the health of vulnerable workers. ome to both of you, and i would ask -- i guess we need to pass the clicker to the lady who is next. dr. lewis. >> good afternoon. as you all heard, i am a board-certified pediatrician, so

i tell folks that i have 55,000 bad kidses under my care. what i'd like to do is to give you an overview of the georgia department of corrections which i think is a reflection of a lot of other correctional departments throughout the -- throughout the united states. fortunately, we've had lots of success in improving the health care that is being delivered to the inmates in our custody and fully respect theestel versus gamble ruling with mandated health care. to start out, georgia has a little bit of a difference here. we're the ninth largest state in overall population, but with the fifth largest prison population. we have roughly 55,000 offenders in prison and about 145,000 probationers.

94% of our population is male and 6% is female, and i think that this is, again, a reflection of other states. the male population, unfortunately has a predominance of african-americans. 62% of our population is age 25 to 45 chronologically and i'll speak a little bit more in just a second about that. 50% is over 35. so you think about your general population in the free world and how we mirror what is in the free world. we operate 120 facilities, 31 of those are prisons. we also operate county and private prisons, transitional day care and day reporting centers and probation detention centers and boot camps and again, we're responsible for producing constitutional -- providing constitutional-mandated health care. does everyone understand what that is? it means there are basically three minimal standards and one

is that all inmates have the right to access care. secondly, they have the right to care that is ordered and thirdly, they have the right to professional opinions of those providers to order that care such that the example that i give is that we can't have a dentist that tries to do an appendectomy, so that's the third piece of it. our demographics are such that 37% of the inmate population has significant chronic illness. that number in percent is up after about four years. four years ago it was about 33%, and i think that every state is challenged with this where they have an increase acute to chronic disease and the disease is the most prevalent and our hiv, cardiac, hepatitis c and mental illness and cancer. 17% of the georgia population receives mental health services

and there's some difference with that. in the female population, 50% of our female population is receiving mental health services compared to about 12% in the male population and we think that's attributed to cultural differences and then mostly in the female and it is behavior disorders and it is the mood disorders. we have most of our inmates we say kron logic age, their physiologic age exceeds their kron logic age because it exceeds incarceration. they have drug use, lifestyle factors of smoking, deficiencies and lack of activity. they have minimal to no health care, either medical, dental or mental health and have an accelerated listing of chronic diseases. we have an increased population of aged, blind and disabled and our older, our admission age is

older. the average now is about 33 years of age and then it therefore translates into our older age of the population which is about 36 years. so we're not getting more young people in that i call, but rather, you know, the older folks are starting to come in. in fiscal year 2013, these are some pretty startling statistics for us. those that are over 35 years of age represent 54% of our population and account for 75% of the claims. those that are over 50 years of age are 18% of the population and account for 47% of the claims, but most importantly here is those that are over 65 represent 2% of our population, but account for 8% of the claims. so if you're looking at $180 million budget, that's a lot of money. those that are over 65 years of

age and their average claim cost that's around $3500 versus those that are less than 65 years of age representing only 591 and that's a dramatic difference just based on the age. here, i'd like to look at the per diem budget. over the last, at least five years, each year the department of corrections has been given a reduced budget. so we have this budget that is continuing to be reduced. we have the mandated constitutional health care that we have to provide. we are continuously having an intake of chronic illness which includes those women that come into our population pregnant and we're responsible for the prenatal care and delivery and they would be high risk so all of the services that we are required to pride, we're having to get very creative in the strategies that we use in order to provide that necessary

mandated health care. the covered population that you see listed below represents the population that's covered in our general population. we have probably about 6,000 inmates who are housed in what we call private prisons. they have several prisons within our state that take it so that the cost for that does not come out of our per diem there. so, again, here's our creativity. as you heard, i have a long history with managed care organizations and whether you like them or don't or whatever, it's the world we live in and they are successful. so some of the principles that those managed care organizations have used, we have applied in the department of corrections. the first one being and i'm very proud of this is called the summer of health care benefits and it is the same document or a similar document that you receive when you sign up for your own insurance.

it basically tells you what is or is not covered and is or is not eligible and basically, what the insurance company will and will not pay for, but for us, it listsous what services are eligible to the inmates and which aren't and it puts everyone on the same playing field because the inmates understand which services will be covered and which ones are not and also the providers of those services understand which services are eligible and to give you examples, we don't pay for umbilical hernias or outies and we don't treat your acne or male pattern baldness and we don't pay for your sex change operation or sexual activities. so those are the kinds of services that are not considered eligible. all other medically necessary services and those are the key words, medically necessary services are provided to the inmates within our custody.

this do you mean has becument h by the office of attorney general and the constitutional health care. the second foundation is preventive care. i know you've heard an ounce of prevention is worth a pound of cure and it is of no benefit to deny preventive services. we follow u.s. task force for preventive services guidelines doing routine health assessments and providing chronic illness krinices with the necessary medications that go with that and on a frequency and fortunately, we have a locked up population and the fact that they miss an a poim, that doesn't happen very much. they get to come when they're supposed to come. we have an active yacht liezation department that does preauthorization with concurrent review and planning. we have an active pharmacy and

therapeutics committee. we have a formulary and a co pf pay which is legislatively mandated and it's $5 for those prescriptions that are considered to be non-chronic care and it's prescriptions that the inmates come in and say i want. i want this. i want that. well, it's a $5 co-pay. thirdly, under pharmacy, we have been fortunate because of our relationship with the medical college of georgia now known as georgia regents to be able to have access to 340 of-b pricing for some of our purchases primarily right now for hiv drugs. we actively manage our network, both of hospitals, physicians, ancillary services and medical kim, physical therapy, occupational and rehab. we have a compassion and reprieve process so that any inmate who has a guesstimate life expectancy of less than 12

months from a terminal or chronic disease can be considered by our board of pardons and paroles which is the clemency entity within georgia to be considered for early release. we have telemedicine and telepsyche which has allowed us to extend provision of medical services not necessarily on site, but through the telecommunications. we have a modular circular uniity in one of the prisons where we are able to take the prisons to on have that done and we have a forensic unit in one of the hospitals that has 22 beds and the purpose of most of those is so we have found the more services that we can can provide behind the wire rather than sending the inmates out into the community, it is both cost effective, cost efficient and our first goal is to provide public safety and that is the

rhymary purpose with that. so we do a good job, i think, in providing and getting very creative and providing more and more services behind the wire. our challenges are again, the grain of the inmate population. all states are experiencing inmates aging because they have longer sentences, longer confinements and all of the illnesses that you experience and that the free world experiences with getting old, our population experiences. all of the mobility issues, you know, the cancer and all, we experience that. they have physical incapacity and immobility and progressive degenerative diseases. we have an increased concentration of chronic illness and this is in the face of diminishing budgets for health care and with that diminishing budget we have to get very create of because there's increased liability associated with that funding decrease.

we find that we have to establish protocols of who will get treated for certain diseases because of the treatments being so incredibly expensive. we have an increased mental health burden with dementia, depression, psychosis and the cost of the psycho tropic medications and we experience barriers to re-entry which includes transition of medical care to appropriate providers. you can imagine that a lot of providers out in the community are not necessarily opening their doors and welcoming someone who is being released from prison. oftentimes they come with no benefits and no resources to help pay for their services. vocational certification and employment opportunities is also a barrier. in georgia, we have a law that basically says that those who become, quote, certified like a certified nurse assistance cna that can provide services in a nursing home, that certification doesn't hold up once they are

released. they are not able to use that and thirdly, the residents' restrictions those for sexual abuse and those confined from a sexual sentencing. they have a thousand-foot yard rule with churches, schools, parks, et cetera. so the recommendations that i would have based on all of these is that 340b pricing would be made available and much more easily available to the departments of correction throughout the united states. we would establish guidelines for the potential impact on the departments of corrections regarding the affordable care act so that we're not kind of figuring it out as we go. thirdly, that we would promote electronic health record exchange meaning that, you know, electronic health records would be able to be exchanged through all venues from the prison system, through the jails on out into the community providers and

lastly, to expand federal funding partes paying for inmate eligibility to help offset some of the cost with the prison system. thank you. >> thank you. >> okay. >> thanks, dr. lewis. let's turn to dr. turney. >> good afternoon, everybody. my name is asher turney, i'm a medical doctor from rural alabama and tennessee. i've been a doc for about ten years, and after hearing some of the discussion earlier from miss bay and row. i just want to say we all can have a family member that can be incarcerated and i want them to get the best medical care. i work with the department of corrections and we try to avoid

some of those circumstances that they describe. i don't think it's an overwhelming, across t boehe bo pervasive issue, but there are certain situations that, you know, i work every day to prevent. so i just want to say, my discussion today will be a little bit wider in scope and it will be on some of the issues that we deal with in corrections, but as i said, i completely empathize with anyone who has had a circumstance like that because that's what i went into medicine to prevent. like i said, i'm a preventive medicine, urgent care specialist and i went to the medical college and our goal was to help the underserved. this group is the underserved. it's the same, vulnerable population that oftentimes that fail health care centers and this is the same population that needs access and it's the same

job for me whether i'm behind the walls or not. so, i just wanted to kind of describe our situation in tennessee. i am a vendor partner to the department of corrections. i work with centurion, which is a company that has about 60 years' experience in managed care, also in correctional health care. my parent company centene and mha services provide us opportunities and tools that we can can fulfill the individual state's needs. we provide care to the greater service on the centene sides and as well as behind the bars with centurion. we provide local solutions to some of the most difficult situations our partners face, but we also use evidence-based medicine which is probably something that is a newer term it, but we use evidence-based

solutions and leveraging technology and predictive modelling and innovative health models to limit incidents and the severity of disease just of some issues to note. so tennessee, welcome to tennessee, everyone. we a we are have 21,000 inmates across the state and roughly 11 facilities and roughly 11 facilities and we do have some challenges. each state has its own, unique challenges and obstacles as it relates to the correction of health care and we've worked really hard to improve some of those issues and make them -- make them more manageable. the population as a hole, just in general, the general population has been affected and those same issues mirror in the correctional population oftentimes, sometimes it's

magnified like we talked about hepatitis c as an infectious disease or mental health illness. you have a significantly higher rate of mental health illness, excuse me, within corrections than you do outside the walls. and we've tried to to deliver solutions to the tdoc that improve those concerns. centurion has managed the tennessee contracts since september 2013. we have efficiently decreased the numbermissions to the hospital and e.r. by treating on site by getting in earlier with the model to decrease hospitalizations and trying to set up program before we get to patient before we have an exacerbation that requires an e.r. run. we've also trayed to install what we've done. across the state we've installed -- telehealth, excuse me, and telehealth, just to kind of really quickly refresh is a

mechanism by which you can use an internet connection or video and telephone to centrally discuss with a professional on one side and an inmate patient on the other with a nurse and have a facilitated medical visit and it allows you to get to the patient much sooner because in the past you'd have to transfer outside the walls. we brought that onboard and it also decreases the -- reduces the risk to the public safety of transferring and it saves money standpoint of transportation and security. we've also developed in some new on-site services which are continuing to improve the overall health and well-being and i'll talk a little bit more about that on the next slide. i do want to say this just to kind of tag along to dr. lewis' comment. managed care philosophies are improving health outcomes at least in tennessee.

so i wanted to just briefly discuss a few considerings and this is not an exhaustive state of conditions. mental health disease or illness, excuse me, is pervasive in the correctional population so we have to bring in innovative, multi-disciplinary approaches so mental health, medical, legal, corrections, everyone at the table to ensure that these patients get the care that they need and our patients, oftentimes especially in the female population, they have a history of being a victim to violence and substance abuse and those do make more complicated treatment pathways.

as far as unique populations within corrections, i think we all have elderly populations. we take care of them whether you're inside the walls or know, but the difference in corrections is that the elderly population and corrections is physiologicly older than the chronological age. so you have a person, the life expectancy of a patient that's been incarcerated, that's the way i see them, i see them as patients, late 50s, whereas the general population is much more near 70 or 75. so it's a huge difference so these patients are showing up to our door much sicker than they would have been and much further along in the process of neuropathy, whatever the worst-case scenario they might be and it's a lot more difficult issue than probably has been previously discussed, but as far

as older populations we try to look at aggressive chronic disease programs and we're developing on site, long-term care facilities to provide assistance to, say, a demented patient or a patient that needs nursing care. we roadwayed hospice care and we understand cancer increases in incidence as we age and we're having more patients with cancer and we're trying to treat those humanely and respectfully on site. as far as our -- i'm sorry. as far as our female population, females as a group, they have a higher incidence of mental health disease versus the male counterparts. we have less than 5% of the inmates are female and they have significant mental problems and it's a totally different environment to treat patients and we do try to ibring

innovation to their care. say with pregnant patients we provide centering. it's a new concept and it's been evidence based and it shows essentially you work with a group of patients instead of one patient and their experiences can then be exchanged and they learn from the grouping. so instead of the one to one doctor to patient ratio, you have a been to five or a larger group where you can have a nice exchange and it facilitates better customer service and we do care about our inmates and their considerations about the health care and it proves better outcome so we have less pre-term babies and larger birth weights. so it's a good thing. lastly, hepatitis c, and that's the elephant in the room. hepatitis c is a very concerning illness, okay? it is -- it has surpassed hiv as the largest cause of death or

highest cause of death for a viral illness as of 2007. our populations nationally, 17% or so, 17 point-something percent of the inmates that we have incarcerated have hepatitis c. okay? almost one in five. in tennessee it's about ten times the general population's rate. so we have about 10% roughly. there's no vaccine available. it's not like hepatitis b, and unlike hiv, hepatitis is potentially curable. the new medications that are available may -- may lead to that, but they're very, very, very costly and difficult to get. so we are working toward aggressive management of our hepatitis c cases as this is a public health issue. we don't talk about it often, but a large percentage of inmates will be released and we

want it make sure they have the least issues so that they can have a most successful life and contribute back to society. my goal is not to be the yuj and jury. my goal is to provide health care for them. so, you know, talking a little bit more about innovative programs in -- in corrections and as we talked about earlier, it decreases the need for transfer, including costs of staffing for officers and it reduces the time of diagnosis and it reduces the public safety risk. we also go further to -- pardon me we also go further to go beyond just the treatment model. we look for prevention. we as an organization are are moving toward a more customer-driven model and i think empowering, you know, if

you look at, like, 20 years ago when managed care first came around for 20-plus years now, actually, but when they first came around we were more focused on providers, networks facilities and now we're actually focused on patients, consumers and we do that through wellness programs. we do that through education and this is a correction. we have a program called nurture. it can be group or individualized, but it's a telephonic disease program that provides wellness to the inhama. for example, a nurse can speak to an expert. this goes beyond having a practitioner on site, but having an expert. say diabetes. y'all have a diabetic expert talk to you and counsel you on mechanisms to improve your

health and it's been shown outside the walls to be very successful and we're in our terminal negotiations to implement it across our state. so these are goals that we're trying to implement to improve the ultimate health and well-being of the patients. as far as the future, the future is re-entry in some cases and in those cases we want to make sure we provide a bridge, and electronic health record as one of the guests asked earlier would be a great bridge because it provides the information and efficient means to get to on safety in a hospital or to a community health care center or to on some other group upon that can provide health care after the patient has been -- um -- um -- discharged or the sentence hasec piered. at this moment corrections as a whole does not have that opportunity. there are a number of

difficulties of getting in the system and i think that that would be a potential opportunity for policymakers to look at finding a way to improve it it because this is ultimately like we talked about, public health and it can cut to the u.s. public health system in some way where that information, before they come in can then connect to while they're in to when they get out and it be a complete pathway or complete life cycle and that will ultimately help the patients in the long term and that's one of our goals. like i said, centurion is a company, and i am completely in support of taking care of people when they need care and we try to find individual solutions to our state's concerns. i want to just focus everyone on the recommendations. my recommendations for policymakers at this point will be to look at integrated methods

to provide behavioral or medical care on sites before and after entry and re-entry. consider electronic health records as a mechanism through, maybe through high tech or through some of the other funds that are still available and find a mechanism to assist department of corrections in developing an electronic health record so we have an ease of communication and it helps decrease unnecessary reoccurring medical business because you have the information from the previous medical visit and oftentimes they will reord onner what the previous doctor has because they recognize it hasn't been done and they don't have the information immediately available and they have to make a decision then because they have it on their shoulders. lastly, to continue to develop the discipline of correctional health care by empowering department of corrections and other medicalstitutions to

partner and have medical residency programs and medical students and allied health professionals and provide some type of funding to assist the department of corrections in hiring qualified professionals similar to the national health service corp where you have difficulty with accessing health care, they arc lou mon allow mo and that's how they recruit more nurse practitioners, et cetera. thank you. >> thanks very much, dr. turney. we have about 20 minutes now where we can get some our panel and give you a chance to ask some questions as we go forward. you can hold up a green card, go to a microphone or tweet, and

i'd like to get us started if the folks at the microphones would fore bear just a moment. >> yeah. >> if i can get all of our panelists to really talk about something that was raised earlier in the program and asher, you were talking directly about delivering the kind of quality, evidence-based care that is the standard as we go forward and dr. lewis, as well. what kind of standard have you talked about the need for regulation and oversight of the proprietary providers of health care in prisons or the proprietary prisons providing health care. what kind of a mechanism for oversight and what kind of standards are in place that you either have to impose or live up

to in the case of dr. turny and steve, maybe you can talk about the broader picture to go beyond the specific states that are represented here. >> i think part of it just shows the alliance's gift to represent. and dr. lewis because of her personal background in managed care and because of dr. turny and because of the commit am to use managed care principles within a correctional institution has demonstrated the managed care principles and i think in both instances it's a question of self-regulation that's occurred both in georgia and tennessee that shows the progress that dr. you lookis and dr. turney has created. the larger question i'm hearing you ask is should there be some other regulatory type framework that would regulate correctional health, and i'm not prepared to answer that question one way or the other, other than to say as we both heard dr. turney say

that because of their commit ams to managed care principles that they've been crossing that bridge over to the island of corrections by using managed care, electronic records and telehealth as mechanisms to cross that bridge. as to whether there should be other mechanisms i'll leave that up to those of you who get to stay here in congress to figure that out. >> dr. lewis, what do you do with those private prisons? what standards do you hold them to? >> they're held to the same standards with our s.o.p.s, as all my facilities within the state. we perform annual audits to make sure that they are delivering the health care by the standards that we have outlined within our standard operating procedures within the department. >> we, too, the standard of care is no different inside or outside the walls. so we are held to that same level of care. we'd have to defend it in court

otherwise. what i will say is that we internally also do audits in addition to our state agency partner. they do audits on a regular basis, but we do audits internally to ensure quality measures and we are american correctional associations certified and some of the other contracts are national health care certified and those also have rigorous standards similar to the quality commissions. is it part of your contract negotiations, as well? i was thinking in terms of your negotiations with tennessee in the case of dr. turney. >> you know, i'm not -- i'm not as familiar with that portion. i can get that answer, but i'm not familiar with that portion. >> steve, in addition to what we might do further, do you have observations about what the

other 49 jurisdictions might look like? we have the picture that d.c. wasn't there at the top. >> not at the time that they were incarcerated for sure. this is part of the state, federal and local partnership that up until now we've aloud each jurisdiction to govern the island of correctional and correctional health as they see fit and at times to having someone like dr. lewis who has something that she brings forth. i think there is no national framework, if that's your question, ed, where we have made a societal decision that we're going to make sure that correctional health follows managed care principles. we have not because of the inmate exception, the typical medicaid protections that are available to consumers have not been available within a correctional health setting because they have not been subject to any of the cms standards or quality review or anything else that's required.

so, frankly, when you've seen one jurisdiction, you've seen one jurisdiction. >> and i do want to quickly. >> we do have -- i was thinking more of contractual and we do have measures in place that our vendor partner would look at frequently and there are incentives to make sure they're running smoothly as far as contractual. >> very good. thank you. >> yes, go right ahead. >> thank you for having us today. specifically, dr. lewis. lots of strategies, i'm curious about once you're outside of the wire, i totally agree, trying to do the best you can inside makes a lot of sense and that structure, never missing an appointment, that's real. once you're outside, unless you have a really strong community intervention and we're able to coordinate that care from inside to outside that wire. how do we encourage those

strategies? what do we do other than create a link with the medical record and things like that to ensure that those folks suddenly thrown out in this community once again, freedom and all of this time where they were more successful in a structured environment and made those appointments, how do we encourage and make sure that once they're out they're a part of something. thank you some. >> i think a couple of things. one is that we can do a better job at trying to educate the inmates about their illnesses during our chronic care visits so that they have an appreciation for the severity of the illness. secondly is identifying public health providers that are going to be willing to accept those discharged inmates into -- under their care. we're having some difficulty with that, but it's hard to say, but the more catastrophic an illness is for an inmate, we have discharge planners who try

to coordinate the care upon discharge. for someone who simply has hypertension or diabetes that's well managed and unfortunately, we're not doing as good a job of trying to hook the links up on the outside, but those patients that have cancer and chronic diseases, major chronic diseases, we try really, really hard to coordinate the care with the a poim ppointments at leaste beginning. we give them 30 days of medication to get them started. we try at least six months ahead of time to identify and research what benefits that are available for them with medicare, medicaid veterans and try to get the paperwork started so the resources are in place until they get discharged. >> we're seeing a difference between expansion and

non-expansion state and these folks are being able to come out with insurance and the non-expansion states both dr. lewis and dr. turney can speak to the challenges they're having and having providers that are essentially a no-pay patient. >> you want to identify yourself, please? ? i'm a longtime, life time public health official and in an expansion state and it seems to me that a real lever is consumer education and also with the state contracting because in an expansion state, the state is paying for corrections and the the state is paying for medicaid and so in order to coordinate those benefits, on the hospital side we're looking at accountable care organizations so hospitals are coming out and working with community providers to make the discharge meaningful to avert unnecessary readmigs and we're not doing that and maybe someone on the panel is aware of those innovations with following that individual in a

contractual arrangement so there's risk sharing or savings sharing by the corrections officer as well as by the public health rf. i ask anyone on the panel. >> there is an example of that in argon and part of their ccos. they actually have set up a separate post-incarceration cco contractually which has a risk-sharing arrangement with that. that's the only one that i can think of off the top of my head that the state has done that. i think that's a great model and that's a great example we want to do. the question is that given the federal system and federal, state and local autonomy is how do you stimulate and encourage those types of programs? is that a federal grant program or an initiative program? but yes, it's an excellent point. >> great panel. thank you. >> we have a question right there. >> oh, yes, here we go. >> my name is ricka and i'm with

the national association of community health centers or nac and my question is to mr. rosenberg, but anyone who has input. so as a staff member at nac, we have thousands of member health centers nation wide including those in partnerships. in addition to your island metaphor, i want to point out that the correctional system is also hidden behind concrete walls, layers of varying policies that the local state and federal level that are gray, at best. the the inmates are disappeared behind the walls and they're labeled criminal and the incentives for keeping it that way. so from your experience of success building these partnerships at the community lev level, i'm wondering if you have any words of wisdom and lessons learned that you can share while we're at this national level and have the local member health

centers that could potentially want to reach out and create these partnerships and may not know where to start or who to contact. >> i want to identify a huge obstacle which i think you know about which has been unwilling to allow health centers to have a scope within service to find care behind bars. while you have the health centers that are the number one appropriate provider to be going out and providing care behind bars, it has not been able to allow that change for scope of service. for those of you who are here on the hill i want to point out that that's not an insignificant issue. in terms of lessons learned going forward, i think the number one thing is about understanding, having a community board, community health centers are 51% user boards and having that community board, understand and identify that the folks behind bars are members of the community who are temporarily displaced and that's an educational process within

the community health care movement and if you look at ashe, who started this model. he started it by him identifying that the folks in his county jail were community members displaced and he reached out to the local community health certains to provide care. that came from the correctional side. i think the challenge is from the health center side, having an absolutely educational understanding that these are the fathers, brothers, uncles of the women and children we primarily serve and that they are a part of our community and as such we want to reach out into, behind those barbed wires and steel walls and guard towers to figure out how we create integrated care and the samhsa version is another good model for that to be disseminated out to health centers. >> yes, ma'am? >> hi. so my name is amy testimony as and i work for the community of

affiliated plans and we represent 58 non-profit managed cares throughout the country and we have one in particular in rhode island that is working with their health services department as well as the prisons to help with that handoff between, you know, the prisons and them coming outside and i particularly was curious if you have any research about the return on investment. we're looking at this on on rhode island, but any research that's been done about how the handoff it you willy saves state medicaid programs money. >> and the answer is no because of data sources. so the washington state data i was able to describe to you is unique because they merge their jail booking data and their medicaid data and their mental health utilization data and it allows them to tie that data. no other state has that data at this point in order to be able to do that research.

and the correctional leader, and and they link, and we have a master patient index or some way of tieing that data together and we don't have a way to do that and there are a lot of hipaa concerns and other concerns to do that and they weraible to do that again because of the unique data set that allow them to easily identify folks. >> okay. we have just a few minutes left. i'm going to ask you as we go through these last couple of questions to pull out the blue evaluation form if you haven't done it already and fill it out as you listen so that we can get some feedback on -- what we ought to do to serve your needs better. >> just a very quick question. yes. both of you talked about hospice care and long-term care inside

the prisons and i was just wondering why can't these people be released at that point? why are they still incarcerated when they probably are not a threat to society anymore? just wondering. >> for georgia, our clemency entity which is what we call the board of pardons and parole has the authority and we have an active medical reprieve process. right now we probably have 65% of those inmates that we submit for consideration that are being granted a reprieve. so those inmates who have, as i said, a guesstimate life expectancy of less than 12 months or a chronic termial or otherwise disease that will be particularly costly to the state we can submit those for consideration. we have a similar process in tennessee, but our providers

would be responsible for providing those cases to the department of corrections and they would go through the normal process. the process has been reese leent revised to include some long-term issues that are not, per se, terminal, but are debilitating to be humane. >> this is the last question and maybe the toughest. what do you anticipate the new hepc drug having on correctional health care expenditures? >> the easy answer is bankruptcy. and therefore, what? dr. turney was talking also about trying to deal with very large incidents of hep-c

population. are you going to prioritize? are you going to test everybody? are you going to allow the use of civaldi for some subset of those folks and how are you making that decision? >> you want to take it? >> we're going to and have started to prioritize those inmates and basically leave the decision to the g.i. specialist who is rendering the care as to who is most appropriate given the financial constraints. civaldi is a very effective drug, but to treat an inmate with fewer side effects which is the big plus for that roughly $120,000 so with that type of price tag you can imagine we can't treat everybody for $120,000, otherwise we wouldn't

be able to treat the heart disease, diabetes and everything else. we do have to prioritize and we do have to follow protocol and we have to look at the federal bureau of prisons guidelines for treatment of hepatitis c. >> asher, you want to weigh in on that one? >> it's not an easy answer. we have a long way to go with the discussion and there has not been any defined schedules that have been released on a national scope. the aasld and the fbop have released preliminary guidelines which we also use. we have an advisory committee that has an infectious disease doc or hep atoll gist based upon their medical needs. case in point, hepatitis c and hiv, they don't work well together and they have both illnesses your disease goes much faster and so they're put at the top of the list.

we look for worsening clinical courses and we put them to the top of the list or, you know, prioritizing. so there needs to be still a lot of discussion between local, federal, pharma corrections and public health on this discussion and we really need to find a solution and it's got to be a collaborative deal. >> okay. well, if you could put that composite slide back up, i would appreciate it. just for your use, our crack staff led by marilyn sa rshg afini on this one has put together a summary of the evaluations that several of our speakers today have put into their presentations. so when you're looking for things that you can work on, we've put it all on one-page for

you. so take that as grist for your legislative mill or policy mill. i want to thank you for your attention to a really to the under-appreciated set of issues that we were able to address and for that, by the way, i want to thank our friends at centene for allowing us to put this program together and helping us recruits some of the folks you've heard. i want to thank our panel and particularly, i want to recall the eloquent testimony that we heard from deborah roe and jacqueline craig bay as well as the panelists you see up here and ask you to join me in thanking all of them for a very useful discussion on a very difficult topic. [ applause ] >> and thank you ed.