It’s Time for a Talk About Measuring Cost and Corrections

Against all advice, Dr. Anton Chekhov set out in thespring of 1890 on a 3-month journey, largely by sled

and cart, across Siberia to Sakhalin Island, where hewould single-handedly perform a survey of the penal col-ony’s 10,000 inmates and exiles using a 13-point question-naire printed on 4-by-6-inch cards.1 Why did Chekhovcommit himself to such a herculean task, already havingleft regular medical practice, already a winner of the Push-kin Prize for Literature, already coughing blood fromtuberculosis? “Sakhalin can be useless and uninteresting,”he explained to his publisher, “only to a society that doesnot exile thousands of people there and spend millions onit.”2

Humanitarian advocates routinely make appeals toeconomics, reason, and science. Such appeals commonlybump without consequence into the intransigence of politi-cal reality, but there are exceptions. In this issue of theJournal of the American Geriatrics Society, Ahalt and col-leagues3 advance a simple plea for data about the health-care costs of older prisoners. This plea may well havearrived at the right time. Public discourse on incarcerationhas increasingly taken a bipartisan turn focused on cost4

as associations of states5 and counties6 begin to grapplepragmatically with correctional budgets that are squeezingother essential services. All parties can cite riveting facts.New Hampshire prison medical expenditures, for example,increased 372% from 2001 to 2008.7 Health care repre-sents 31% of the $51,889 annual cost to incarcerate anadult California prison inmate, equivalent to $1,337 permonth.8 I manage free-world populations of similar agesfor one-third that cost. The older, more-costly inmates(aged ≥50) increased from 4% of the California prisonpopulation in 1992 to 19% in 2011.8 Our insights rarelypenetrate deeper than this aggregate level, however. Ahaltand colleagues argue that without additional data onexpenditures according to age, condition, and site of ser-vice, grappling with these realities will prove difficult.

Here is where social exigencies offer hope. The bud-getary pain at every level of government is real, althoughpain alone does not guarantee progress. The strategicopportunity of the moment comes from the confluence ofthis budgetary motivation with healthcare reform and themeasurement initiatives of the Institute of Medicine (IOM)and the still-incipient National Quality Strategy. A modestproject on data capture regarding incarceration, healthcarecosts, quality, and outcomes, performed for example, bythe IOM with private funding, would yield significant

short-term, multistakeholder benefits and a pathway to aless-vexing future.

Public officials’ awareness—and anxieties—have risenwith new federal and state laws that shift correctionalhealthcare costs across county, state, and federal levels ofgovernment. My county has already begun drawing downstate funds to pay for acute hospital stays of jail inmates,and in 2014, those costs will move to the federal govern-ment under Medicaid. In 2014, approximately half thepeople released from state and federal prisons will benewly eligible for healthcare coverage.9

These shifts in eligibility raise new questions aboutscreening and treatment protocols, for example, for hepati-tis C infection, the bulk of which aging baby boomersbear. In 2006, approximately 10.7 million unique individ-uals spent time in jails or prisons, and more than 90%were eventually released back into the community.10 Thisgroup represented 3.4% of the U.S. population but carriedone-quarter of the hepatitis C burden.10 Treating hepatitisC to prevent downstream cirrhosis and end-stage liver dis-ease is cost-effective but not cheap. New direct-actingantivirals permit shorter treatments with better responses.Incarceration, which has long been a screening opportu-nity, is increasingly a treatment opportunity. It would behelpful to better understand these costs across episodes ofcare and lifetime duration of disease as we sort out whento treat and who should pay.

Elsewhere Ahalt and colleagues have suggested modestchanges in national health data sets that would facilitateinsights into the relationships between health and incarcer-ation.11 The Medicare Current Beneficiary Survey, forinstance, clumps homeless, transient, jail, and prisons inone question without coding for incarceration separately.The Healthcare Cost and Utilization Project captures all-payer discharge data and codes for residence—but not spe-cifically for residence in prison. The Census Bureau’s Cur-rent Population Survey is similarly deficient, even though ittargets unemployment and poverty.12 Beyond obscuringhealthcare costs and outcomes, this failure to account forincarceration in dozens of national data sets makes itimpossible to understand racial health disparities, giventhat up to one in three black men may be incarcerated atsome point in their lives.13

Nevertheless, correct coding within federal data setsrepresents only a sliver of the challenges and opportunitiesof the moment. Our national conversation about health-care measurement has rapidly matured, and several IOMcommittees have captured a cornucopia of hard-won wis-dom, beginning with Performance Measurement in 2006.14

The IOM’s Roundtable on Value and Science-DrivenDOI: 10.1111/jgs.12508

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© 2013, Copyright the Authors

Journal compilation © 2013, The American Geriatrics Society 0002-8614/13/$15.00

Health Care points out that our measurement systemsmust address multiple purposes and multiple stakeholdersat local, state, and federal levels.15 Performance and costdata are needed for research, but quality improvement,payment and purchasing decisions, reporting and transpar-ency, regulation, and budgeting are as well. For managers,“overall healthcare spending measures need to be the goal,but progress at the local level will depend on specific utili-zation measures, such as emergency department use or theutilization of advanced imaging technologies.”15

Correctional advocates and other stakeholders—particularly public officials hoping for transparency andaccountability—should embrace the IOM’s multilevelframework and practical emphasis on aligning and harmo-nizing metrics, and all parties should recognize the chal-lenges. Making sense of cost data is difficult anywhere andmore so in corrections, given the latter’s irregular use ofCommon Procedural Terminology codes, variation inoff-site unit costs, and healthcare-associated custody costs.The lack of claims data and diagnostic codes commonlyfoils risk-adjustment methodologies. Furthermore, theIOM acknowledges that successful implementation of mea-surement systems turns on organizational and social fac-tors including “organizational leadership, culture, thebusiness case or return on investment, knowledge manage-ment infrastructure, and workforce competencies.”15 Thesefactors are less propitious in corrections than in the freeworld, but in large part this is because the latter has longenjoyed a consistent regulatory framework that promotesreporting and transparency, whereas inmates, their keep-ers, and costs have been out of sight and mind. The jour-ney toward risk-adjusted utilization and cost measures incorrections may take years, but some systems could reportambulatory care–sensitive admissions now. Uniformitymay be critical for research but is not for other purposes.Consistency of cost specifications, for example, may be lessimportant than transparency.

I agree with Ahalt and colleagues that geriatric exper-tise will help meet these challenges. When I was chargedwith addressing aging and long-term care in Californiaprisons, our teams collected invaluable data with standardgeriatric strategies, surveying inmates with functional mea-sures adapted from the Minimum Data Set,16 often relyingon “caregivers” who were more often correctional officersthan nursing staff.17 Rehabilitation expertise is also criti-cal. Two-thirds of those California inmates in the system’smedical and long-term care beds were younger than 55,often afflicted by trauma, including undiagnosed braininjury. No one is at greater risk of pressure ulcers thanparaplegics, yet even our largest jails and prisons can lackexpertise regarding pressure ulcer prevention and treat-ment—and disabilities in general. The average hospitalcost for a Stage IV pressure ulcer has been reported as$127,185, not including outpatient costs, malpractice set-tlements, or, in corrections, the associated costs of custodyoutside the institution.18

The Affordable Care Act mandates a National QualityStrategy, recently described as the “quality measuremententerprise of the future,” that will reduce disparities andturn from cost of hospitalizations to costs of episodes andtotal costs of care for populations,19 but this strategy of“aligning measures around patient-centered outcomes that

span across settings” has yet to cover jails and prisons.With one exception focused on prisoner research, recentIOM reports ignore correctional health care in spite of thenumbers and strategic importance of the incarcerated pop-ulation. “The intersection of quality improvement and theHealthy People 2020 effort … make this a time of greatopportunity to create platforms on which public healthand health care can begin to use the same language,employ some of the same metrics, and work together tobring about the shared goal of long, healthy lives forall,”20 yet neither the Healthy People 2020 objectives northe IOM report just quoted even mention the relationshipsbetween incarceration and health. The need for a bridgebetween corrections and mainstream policy-makers isbidirectional.

Now would be a good time for the IOM to bringthese communities together. Amid current financial pres-sures and calls for transparency and accountability,an attractive measure set might be readily adopted in cor-rectional systems. Chekhov’s report on Sakhalin Island gal-vanized a national conversation about Russia’s penalcolony. Our own penal institutions are the largest in theworld and have an enormous effect on our public healthand public coffers. It’s time for a data-driven conversation.

Terry E. Hill, MDHill Physicians Medical Group, San Ramon, California

ACKNOWLEDGMENTS

Conflict of Interest: From 2006 to 2009 Dr. Hill wasCMO and then CEO of the California Prison Receiver-ship. He has been an expert witness for plaintiffs anddefense in lawsuits involving corrections. He continuesto serve as a medical expert in a class-action lawsuitagainst Los Angeles County on behalf of inmates withdisabilities.

Author Contributions: Terry Hill is solely responsiblefor concept, design, and preparation of the manuscript.

Sponsor’s Role: None.

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