Hernia Repair in Corrections: Now? Later? Never?

For most medical conditions, incarcerated inmates receive care that is equal to, if not better, than what is available to the average American. I think so, anyway. Often, in fact, inmates have easier access to medical services and receive even more attention and more care than their un-incarcerated counterparts.

For some reason, though, one exception to this general rule is hernia repairs. Some correctional facilities seem to have a policy, whether official or unofficial, that they will not approve hernia repair unless they absolutely have to.

Instead, I will argue that repairing hernias early in their course is both good medical practice and also cost-effective medical policy. Bonus!

hernia alert

I remember when I became aware of the reluctance of some correctional institutions to repair hernias. Soon after I first began working as a jail doc, I saw a patient who had a grapefruit-sized inguinal hernia; big enough that he literally had intestines in his scrotum. This inmate had recently been released from prison (pardon me if I don’t say where), and so I asked him why he had never had his hernia repaired while he was in prison: “I tried.” He said. “They said it didn’t need to be done. They said they would do it if it got worse.”

I assume that what was meant by “get worse” was for the patient to develop some sort of complication (like incarceration and strangulation) that forced an emergency surgical repair. Of course, by the time hernias get as big as a grapefruit, the risk of incarceration or strangulation is essentially zero. Such hernias are also easy to reduce, though they won’t stay reduced.

I’ve seen enough similar cases since to realize that this is not an uncommon situation: correctional facilities often don’t repair hernias.

This would not happen to an insured patient in the outside world. All insurance entities will pay for hernia repair. This includes Medicare, Medicaid, the “Blues,” HMOs, you name it. Not only would they authorize the repair of a grapefruit-sized hernia; all of them would have approved the surgical repair of this man’s hernia way back when it was small.

I know that this is true because I myself once had three small hernias at one time (my nickname at the time? “Lumpy.”) My insurance approved my surgery despite the fact that the hernias were basically asymptomatic. In fact, I had much more difficulty getting pre-authorization for a stupid shoulder MRI than I did getting approval for hernia repair.

So why the disconnect? Why do some prison systems approach hernia repair so differently than outside payers?

One possible reason would be that most hernias do not need to be repaired urgently. They can wait until a convenient time. I myself waited almost a year to have mine fixed—until I could fit surgery and recovery into my work schedule. But it is never “convenient” to send an inmate to the hospital. It is always a logistical hassle.

Also, correctional entities may think: “What is the point of paying for surgery on someone who will be getting out of custody soon?” We are all trying to save a little money and here is a problem that can wait. And wait. And wait. And then the inmate is released!

However, this reasoning only makes sense to me if we are talking about a county jail where, say, the patient will only reside for days to weeks. It makes less sense in a prison where he will remain for years.  The problem with hernias is that they always get worse with time. They never spontaneously resolve. Over the course of years, we can confidently predict that hernias will grow and grow and grow.

For many disease entities, it makes sense to see if they will resolve with time. For example, you often don’t have to do surgery for acutely herniated discs, even if they are causing neuropathy. A high percentage will resolve spontaneously.

This is not true of hernias. Hernias will not go away. You can confidently predict that they will get worse as the patient ages. As a consequence, the patient is not going to stop complaining about it. This means that there is a substantial cost to delaying hernia surgery—the time and effort required to follow the growing hernia year after year and to respond to kites, complaints and grievances.

Another important issue with hernias is that nowadays, repair of simple small hernias is a quick-‘n-easy day surgery, done laparoscopically. On the other hand, the repair of big, grapefruit-sized hernias is not quick-‘n-easy. It will entail admission to the hospital, an open incision, mesh and a fairly high rate of complications.

A consideration of these factors is why Blue Cross and the other outside agencies will almost always approve the repair of a small inguinal hernia. They save money in the long run by approving hernia repairs early on. It is simply cost-effective to repair hernias early, in a younger, healthier patient, using a simple laparoscopic technique rather than wait several years and then do a more complicated repair of a bigger hernia in an older patient.

There is a lesson here for those of us making these decisions in corrections. I am not saying that all little asymptomatic hernias need to be repaired right now. Most hernias do not need to be repaired urgently.

But hernias get worse. With enough time, all hernias should be repaired. At some point in the continuum between the small asymptomatic lump and the grape-fruit sized mass, the repair should be done. As a correctional provider, you can pick when that repair should be scheduled. But to postpone, procrastinate and delay until the patient has intestines in his scrotum is simply bad medicine.

 Summary

1. While there is no need to do an urgent repair of most hernias, especially small asymptomatic ones,

2. Hernias predictably get worse with time.

3. And it is easier and safer to repair small hernias than big hernias.

4. A bonus to repairing hernias early is that you then do not have to deal with the ongoing evaluations, kites, complaints, and grievances about the hernia.

5. Overall, it may be cost-effective to repair small hernias than wait until they get big. Outside insurers think so, anyway.

 

That is my opinion, anyway. As always, feel free to disagree! I could be wrong. Please comment!

 

6 thoughts on “Hernia Repair in Corrections: Now? Later? Never?

  1. Al Cichon

    All too true – for me working in jail – the determinants are duration (if present for months / years with no patient effort to repair -why?); symptoms (the range and severity); debilitation (if any?); and most of all risk of imminent complications; and of course length of remaining stay.
    On parallel note – one of the phrases that has disturbed me is the one dealing with parity. Inmate health care should be consistent with the services in the community.
    In my, occasionally not humble enough, opinion – the parity state should include two conditions: 1.) when there is an established diagnosis (or at least reasonable evidence of same; 2.) the correction community.

    Reply
    1. DBrown

      Our facility does not approve any hernia repair requests unless it is absolutely needed. Most of the inmates I encounter have had the problem for some time and because it is convenient the inmate want to have a repair done because now we have nothing but time and have not made an attempt to pursuit the repair on the outside. Our inmates are in county jail for years now and will haunt. Metro have surgery. On the legal and ethical standpoint however plus why wait until the pt. has an emergency and the cost involved at that time. It is tough with the AB 109 law in our state which is California.
      Db

      Reply
  2. Bill Wright

    In Colorado DOC I can get open heart surgery more easily than a hernia repair. I agree that inmates who kite for a hernia have usually had the problem for years and never thought about getting it fixed until they were incarcerated. As opposed to the community standard that Jeff mentioned, prisons, at least here, will put off approval for repair until an urgent situation develops, or the inmate trips over the hernia and gets a head injury. After 9 years of battling this attitude, I’ve about given up.

    Reply
  3. Annie Che

    There are a great variaty of different surgeries that depends on the principals of a prison system and that is actualy makes a big difference to operation as well. I am totaly agree with opinion not to make an urgent surgery if there is no-delay need. Some surgeons can use a laparoscope avoiding open surgery, you take less risks while not doing open surgery, more in details you can find here hernia-treatment.net

    Reply
  4. SDavis

    As DON of the inmate health program in our county jail, it is not our policy to repair hernias unless that person is staying with us for an extended period of time. As brought out above, most inmates have lived with the hernia for a long time and then have used this chronic condition as request for release knowing the cost involved or have so much time on their hands they have nothing more pressing to think about. Just to not make light of the situation however, we would not want to discredit anyone that says they are experiencing pain due to their hernia and it is n ow down into their testicles.Recdently I evaluated an inmate that made those comments and immediately put him on the MD sick call list to find out that he had an extreme case of epididimitis.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the comment, Shelley. Hernias in jail are a different matter than hernias in prisons. Most hernias should be repaired at some point–but the repair usually is not urgent. Most jail inmates are released before the hernia repair needs to be done. In prisons, the inmates are not getting out any time soon, so since you are going to have to fix the hernia at some point, it makes sense to do it when the hernia is small and the surgery is easier to do. Good call on the epididymitis!

      Reply

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