During the 2019 session of the Virginia General Assembly, the Appropriations Act was amended to include language directing the Virginia Department of Corrections (VADOC), the Virginia Commonwealth University Health System (VCUHS) and the University of Virginia Health System (UVAH) to take action related to the provision of health care services for VADOC’s incarcerated population. Specifically, the 2019 Virginia Acts of Assembly, Chapter 854, Item 390, subsections Q and R, directed the following:

Q. The Department of Corrections and the VCU Health System and UVA Health System shall collaborate on a plan to ensure that inmates with long-term or high-cost prescription drug needs receive treatment from a federal 340-B covered entity. The Department shall begin development of the plan as soon as is practicable and report to the House Appropriations and Senate Finance Committees by January 1, 2020.

R. The Department of Corrections shall convene a workgroup to develop a plan for a pilot partnership for a university health system to provide comprehensive health care for the inmates in at least one state correctional facility. The workgroup shall be cochaired by the director of the Department of Corrections, the chief executive officer of the VCU Health System, and the executive vice president for health affairs at the University of Virginia. The workgroup shall jointly submit an interim update to the House Appropriations and Senate Finance Committees no later than November 1, 2019; and jointly submit a final plan for the pilot partnership no later than January 1, 2020. The plan shall include (i) the facility or facilities included in the pilot, (ii) staffing needs for providing health care services, (iii) the amount and structure of payment to the university, and (iv) how the effectiveness of the pilot project will be evaluated.

Based on this legislative mandate, VADOC convened a workgroup including representation from each of the three project partners. Leadership from the three organizations came together for multiple discussions on how best to meet the legislative mandates. The workgroup discussed current practices, access to treatment and pharmaceuticals, and population needs.

Site selection was easily accomplished following discussions and visits to the prisons considered most viable for the potential pilot. Two VADOC facilities were chosen as pilot sites: Fluvanna Correctional Center for Women to be served by UVAH and the State Farm Correctional Complex in Goochland to be served by VCUHS. Fluvanna was chosen as a pilot site for UVAH because of the high medical acuity and facility location. The State Farm Correctional Complex serves as a hub of VADOC healthcare and proximity of this facility allows VCUHS to mobilize providers and clinics onsite.

As part of the workgroup’s efforts, members spoke with physician leads for the Texas Department of Criminal Justice (TDCJ) which collaborates with the Texas Tech University Health Sciences Center (TTUHSC) and the University of Texas Medical Branch (UTMB) for all offender medical care. Dating back to 1993, the Texas legislature directed the establishment of the partnership to address the rising costs and operational challenges involved in providing health care to prisoners confined in TDCJ. Utilizing a “hub and spoke" model, the work in Texas is considered successful and has led to numerous awards by organizations including the National Managed Health Care Congress, the Texas Society of Health-Systems Pharmacists, and the American Correctional Association. Of particular note is how the change in health care provisions impacted the federal court’s oversight of Texas prisons. In 1999, the federal court released medical care issues from federal supervision recognizing that “there can be no doubt that the vast improvements in TDC’s provision of medical and psychiatric care to inmates have been made…there are now two of the state’s finest medical teaching institutions…giving treatment to inmates." In 2001, the federal court relinquished Texas from all remaining federal oversight, including the provision of mental health care services to offenders in administrative segregation.(*1)

Regarding the two legislative initiatives directed by the General Assembly, the workgroup found them intertwined, therefore, best accomplished through a combined effort. After further discussion and research, it became clear the task of providing “comprehensive healthcare," to potentially include behavioral health and dentistry, at the two sites would require extensive planning and possible legislative changes, beyond what can be accomplished within the designated timeframe.(*2) Given the nature of prison healthcare, costs, laws and regulations, risk management issues, and the complexity of the services provided, more time to study and plan for a university operated system is required to ensure a seamless transition from current processes, while providing access to quality care meeting community standards.

To plan such an evolution in VADOC’s health services at pilot sites, a thorough blueprint needs to be developed under the direction of external consultants who can advise the partners and lead the cultivation of a viable pilot for comprehensive care provided by university health systems. All partners agree that external expertise is needed for this and that existing resources and experience are insufficient. UVAH determined that it currently does not have sufficient expertise in correctional medicine, nor does it possess core competencies necessary to plan for managing the comprehensive health and well-being of VADOC offenders. Despite its current work, VCUHS determined that it needs experience managing patients in the correctional environment, as their current expertise lies in providing care to offenders on the VCU Health System campus, as well as assistance with resource assessment and operationalization. For both universities, the issue of risk management requires additional detailed consideration and possible legislative intervention, as attending physicians are not covered under the state risk management plan.

In the meantime, the partners propose interim demonstration strategies to begin this process, with a full planning period to commence July 1, 2020, depending on funding. Providing interim services at the selected pilot sites serves as an important first step in advancing the implementation of comprehensive university healthcare partnerships with VADOC.
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(*1) Texas Correctional Managed Health Care Committee; https://www.tdcj.texas.gov/divisions/cmhc/index.html ; downloaded September 5, 2019.
(*2) Comprehensive health care services refers to medical services involving the concurrent prevention and management of multiple physical and emotional health problems of patients over a period of time in relationship to their families, life events, and environment.