HD52 - Review of Inmate Dental Care
Executive Summary: The United States Supreme Court ruled in the late 1970s that inmates have a Constitutional right to healthcare. While the Court's .decision was directed at medical care, it is recognized that inmates' health care rights also include mental health treatment and dental care. Questions remain, however, concerning the appropriate level and quality of inmate health care. In fiscal year (FY) 1992, the Virginia Department of Corrections (DOC) was appropriated approximately $29.7 million to provide healthcare to an inmate population which totalled 17,007 on June 30 of that year. The department's appropriation funds health care provided inmates either in correctional institutions, in community hospitals, from private physicians and dentists, or at the Medical College of Virginia. \ Health care services within the 37 major institutions and field units are provided by more than 335 full time employees of the department and additional contract personnel, when necessary. In addition, the department employs five staff, who are assigned to the Office of Health Services (OHS) in the central office, on either a full- or part-time basis. The department has a decentralized approach to inmate health care which results in budgetary and procedural decisions being made at the institutional and regional levels. Central office staff lack systematic, descriptive, statewide information about many aspects of inmate health care. The lack of information hampers the effectiveness of the central office in controlling both the cost and the quality of inmate health care. Rather, central office staff act primarily as advisors to correctional health care staff working in the facilities. Item 15 of the 1992 Appropriation Act directs JLARC to examine the increasing costs of health care in corrections and to determine the appropriate level of that care. This report is an interim report on inmate healthcare. The focus of this report is on the dental care provided inmates. Future reports will address mental healthcare, medical care, and the organization and management of inmate health. Department Policies and Procedures Need to Be Revised Central office staff, particularly the chief dentist, are responsible for developing departmental policies and operating procedures. The departmental operating procedure for dental care addresses many important issues. Given the changing composition and needs of the inmate population, however, revisions are necessary to ensure that the procedure provides adequate direction for dental care. Further, central office staff acknowledge that each institution and field unit should have developed institutional operating procedures (IOPs) for dental care. However, only ten of the 37 major institutions and field units provided JLARC staff with a copy of their dental IOPs when requested. Therefore, the following recommendations are made: • DOC. should revise Department Operating Procedure 716 to include areas which should help ensure that access to quality dental care is being provided to all inmates, including those with special needs. • DOC should ensure that all institutions and field units develop and disseminate IOPs for dental services. Dental-Specific Cost Data Should Be Centrally Maintained and Reviewed OHS staff do not adequately monitor and control dental care costs. Since DOC does not have a cost-reporting system that effectively isolates dental care costs from mental health or medical care, the department has been unable to adequately justify the funding of additional dental positions. DOC should isolate the costs of the various types of health care. .One of the ways the department could do this is by establishing individual "cost centers" dedicated to each of the major areas of inmate health care. In addition, the department should ensure, by issuing detailed definitions and instructions to all staff involved in coding expenditures, that the coding of the various sub-object codes is correct and that sub-object codes designated for specific types of dental services are exclusively dedicated to those expenditures. Subsequently, DOC could better identify areas for cost savings. Further, while OHS staff monitor funds for inpatient health care, no other dental care and oral surgery costs are monitored. As a result, cost comparisons of dental care alternatives are not available. Central office oversight of comprehensive, meaningful cost data would enable the department to take cost containment actions and make more informed budgetary decisions. Therefore, the following recommendations are made: • DOC should promulgate detailed instructions regarding the coding of dental, mental health, and medical expenditures at the sub-object level. • DOC should establish cost centers which differentiate dental care expenditures from mental health and medical expenditures. • DOC should ensure that dental care cost data are reviewed by the central office at least quarterly. The cost data should be used in evaluating alternative means of providing dental care and in recommending cost containment actions. Dental Care Service Provision Should Be More Adequately Monitored The number and type of dental care services provided within DOC institutions are reported on a monthly basis on department "morbidity reports." However, the morbidity reports do not provide valid dental service information because there is no standard definition of what the categories on the report represent or what constitutes a patient visit. Since this manual report cannot be used to monitor dental care provision, OHS lacks valid information concerning these services. Therefore, the following recommendations are made: • DOC should develop a standardized morbidity report form with meaningful service categories. Specific definitions of what services are to be reported and how they are to be reported, including what constitutes a patient visit, should be determined. • DOC should consider establishing a computerized database into which each institution could directly enter medical service data. The central office should then use these data to analyze workload differences and to monitor service delivery. Dental Care Should Receive Additional Oversight As noted previously, central office staff are involved in establishing general policies related to inmate dental care. Questions regarding specific problem situations are often referred to the chief dentist. However, OHS should have a stronger role in four areas of dental care service delivery. First, the department has no written policy or procedure which covers the provision of dental care to field unit inmates. OHS' coordination of dental care service delivery for field unit inmates could minimize the use of private dentists and ensure that dental care staffing and equipment are productively used. Second, inmate referrals for treatment by a medical specialist are reviewed and approved by the chief physician or chief dentist, if the request involves oral surgery. However, no similar approval is required for inmates to see a private dentist if the dental services to be provided are not related to special needs (in addition to oral surgery, special needs include dental treatment for hemophiliacs and cardiac patients). OHS should take a more active role to ensure that private dentists are used only when more cost-effective alternatives are not available. Third, the number of referrals made to private dentists' offices are not monitored, nor are correctional institutions required to report on those services. OHS should monitor the use of private dentists, including the reasons for their use, the dental procedures that were completed, and the associated costs. Fourth, annual operational reviews frequently fail to mention the dental care services that are provided. OHS should review dental services as part of the annual operational review of medical services. These reviews should involve using dental staff in completing the reviews, interviewing dental staff as part of the reviews. and sending a written report to the institution's dentist Therefore, the following recommendation is made: • DOC should ensure that OHS takes a more active role in directing and overseeing dental care provision. Chief Dentist Should Devote More Time to Administrative Duties The chief dentist position was created with the expectation that the chief dentist would devote approximately 50 percent of his time to statewide administration of dental services. The other 50 percent would be spent providing dental care to inmates at Powhatan Correctional Center. However, due to pressing dental care needs and staffing vacancies at Powhatan, the chief dentist has not devoted 50 percent of his time to administrative duties. The inability of the chief dentist to devote the necessary time to perform these duties seems to have contributed to deficiencies in the monitoring of dental services. Therefore, the following recommendation is made: • To assist in addressing the oversight and monitoring needs of the dental program, the chief dentist should devote 50 percent of his time as needed on the statewide administrative duties specified in the position description. Internal Resources Should Be Increased For Better Cost Effectiveness Since the number of dentists employed by DOC has not kept up with increases in inmate population, the use of private dentists has increased, and in tum, the dental care costs that can be estimated have also increased. Care by a private dentist is typically more costly than care provided in an institution. This may partially explain why dental care costs on a per-inmate basis appear to be increasing. An additional staffing problem is the insufficient number of dental hygienists, dental assistants, and oral surgeons that are employed. The failure to staff sufficient numbers of hygienists and assistants has resulted in dentists performing duties that could be more cost-effectively provided by hygienists or assistants. The failure to employ any oral surgeons has meant that most oral surgeries must be referred to private surgeons. The department requested additional staffing for both the 1990-1992 and 1992-1994 biennia. However, Department of Planning and Budget staff did not approve the .requests because of budget constraints and DOC's inability to provide anything other than anecdotal cost data concerning the consequences of not receiving the staffing. Equipment and facility limitations provide additional efficiency constraints. Due either to limited resources or an inability to expand facilities. several major institutions have only one dental operatory. Dental clinics with only one operatory encounter delays which limit efficient provision of dental services. Therefore, the following recommendations are made: • DOC should systematically collect and maintain service and cost data to be used in evaluating and supporting the need for additional dental staff. • DOC should prepare a dental care staffing plan that links increased staffing with improved productivity and decreased reliance on private dentists. • As part of the dental staffing plan, DOC should delineate alternative means of meeting the oral surgery needs of inmates. • In conjunction with the development of the dental care staffing plan, DOC should address the cost effectiveness of expanding or establishing specific dental clinics and purchasing additional dental equipment to allow major institutions and field units to treat additional inmates more cost effectively. Inmate Access to Dental Care Should Be Examined by the Department As noted previously, the department may have dental staffing and equipment needs. However, the department could better manage its current staff and equipment. The department has failed to develop any written guidelines which direct where within the system services are to be provided and which treatment needs are to be taken to private dentists. Consequently, access to dental care is generally limited for field unit inmates. Formal written guidelines outlining which major institutions will provide dental services for field units and how many field unit inmates will be treated should improve the equity of dental care access. Further, increased staffing at institution dental clinics could improve dental care access while providing cost savings by decreasing field units' private· dental expenses. Therefore, the following recommendations are made: • DOC should make it a priority to hire full-time staff for the dental clinic at the Botetourt field unit. The department should allow contract positions to be hired to provide dental care at the Botetourt field unit until full-time positions can be established and filled. • As part of the development of the dental staffing plan, DOC should develop formal written guidelines which clearly delineate where inmates residing in facilities without dental clinics will receive dental treatment. • As part of the development of the dental staffing plan, DOC should determine the costs and benefits of adding staff to existing DOC dental clinics to help ensure improved access to dental care while providing cost savings by decreasing private dental expenses. |
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