Every once in a while, because of changing drug prices, I discover that my formulary has become outdated. More expensive medications are on my formulary and less expensive equivalents are non-formulary. Depending on how long the price change occurred before I noticed it, I may have overpaid hundreds of dollars unnecessarily. Oops!
This situation arises more frequently than you might expect. Drug prices can change rapidly. And formularies do not get updated often enough. I try to go through mine quarterly, but, to be honest, it probably happens only once or twice a year. As a result, I miss opportunities to save my jails some money.
Today’s example is extended release antidepressants. For many years, I never even looked at extended release drug prices. I just “knew” that ERs were much more expensive than their immediate release cousins. But wait long enough, and everything goes generic, including extended release.
If you have not yet noticed, you can save quite a bit of money (and time!) by switching to extended release venlafaxine (Effexor) and bupropion (Wellbutrin). Continue reading →
Eyeglasses were partly why I got into correctional medicine in the first place. 16 years ago my local jail was under an ACLU consent decree and was desperate to find someone willing to provide medical care to the jail inmates under the strict terms of the consent decree. They finally found me, reluctant as I was at the time. So for the first two years of my correctional medicine career, I operated under an ACLU consent decree (May Those Days Never Return!).
One of the medical issues that the ACLU was concerned about at the time was inmate eyeglasses. And so, from the very beginning of my correctional medical career, vision complaints and requests for eyeglasses were a hot topic I had to deal with. In fact, I remember that the very first medical clinic I did in the jail contained 3 or 4 inmates wanting glasses. Since I am a slow learner, it took me several years to sort out in my mind how to deal with the whole issue. But I eventually figured out that vision complaints basically fall into four categories, and each should be dealt with in a different way.
1. Distance vision. Typical Medical request: “I am having trouble seeing the television and it is giving me headaches. I need glasses”
2. Reading glasses. “I am having trouble reading. I need glasses.”
3. Vision complaints with medical implications: “My vision has suddenly gotten worse in my right eye.”
4. Routine screening exams: “My yearly eye exam is overdue. Please schedule me to see the eye doctor.”
Each of these four vision requests should be handled differently by correctional facilities. If you set up a “one-size-fits-all” procedure for vision complaints, you will not be operating efficiently and you will make mistakes. I would like to discuss each of these separate complaints in turn:
“I am having trouble seeing the television and it is giving me headaches. I need glasses.”
There are four considerations to take into account when evaluating these requests for distance corrective lenses. The first is that the distant vista that inmates look at is very different from what people outside of jail look at. On the outside, there is a much greater need for distance vision correction; after all, people who are driving need to clearly identify objects far away. What is that object in the road a half mile away? But what is the furthest vista to look at in one my jails? From one end of the pod to the other is, perhaps, 200 feet. When we say “distance vision” in corrections, we are talking about a totally different “distance” than outside of jail. Instead of seeing things miles away; we are talking about seeing things within a room.
The second important consideration of requests for glasses to help distance vision is whether there is a medical need for this type of vision correction. In fact, this is the only factor mentioned by the NCCHC about glasses. Eyeglasses are defined by the NCCHC as “Aids to Impairment” (J-G-10) and says such Aids of Impairment should be “supplied in a timely manner when the health of the inmate would otherwise be adversely affected, as determined by the responsible physician.”
But what does it mean that an inmate’s vision is so bad as to adversely affect their health? I interpret this to mean that an inmate’s vision is so bad that they run into doors, for example. I have actually seen a few inmates with vision this bad in my jails! It makes you wonder how they got along on the outside without glasses! For most others, there is no medical necessity for distance vision prescriptions. Wanting to see the TV better is not a medical issue by the NCCHC definition (in my opinion); nor is the complaint of “squinting at the TV gives me a headache.” (This reminds me of the old medical joke: Patient: “Moving my arm this way hurts. What should I do?” Doctor: “Don’t move your arm that way. Here’s my bill”).
The third factor to remember for any complaint of distance vision problems is that glasses are not the only solution for distant vision problems. If you are having trouble seeing a distant object, whether it is an object right across the room or the object is a deer a mile away on the next ridge, there are three ways to improve your ability to see that object. The first is with magnifying lenses. The deer hunter uses binoculars; the person in the room can put on glasses. The second is simply to get closer. The closer you get, the better you can see the object. The third way is to illuminate the object with more light. If you are having trouble reading a book in a dim room, turn up the lights.
All three methods work well. So if an inmate’s complaints that she cannot see the TV well, one legitimate piece of advice is simply to sit closer to the TV.
The final consideration for distance vision correction is this: While there may not be a medical need for distance vision correction, there may be an institutional reason that a particular patient should receive distance correction. One example is the inmate who is taking classes like the GED while incarcerated, and who needs distance lenses to see the instructor and the whiteboard. You can move the inmate closer to the whiteboard, you can increase the light on the whiteboard and you can have the teacher write bigger, but it may be easier to just get that inmate distance lenses.
“I am having trouble reading. I need glasses.”
This one is much simpler than the distance vision problem above. Reading glasses are, of course, also not medically necessary. However, again, they probably are institutionally necessary. It is hard to argue with an inmate who says “I can’t participate in my own legal case because, without glasses, I can’t read my case documents or do research.” Based on this argument, I think correctional facilities are obligated to have some mechanism of providing reading glasses to inmates. The best way I have found to do this is to put reading glasses on the inmate commissary. Reading glasses are not expensive; inmates who want reading glasses can buy them. If an inmate is truly indigent and wants reading glasses, just give him a pair. It is less expensive in terms of time and effort to do this than to deal with the inevitable grievances, indignant defense attorneys and, of course, the ACLU. (I know!)
“My vision has suddenly gotten worse in my right eye.”
This complaint, of course, has nothing to do with wanting glasses for reading or TV. This is a true medical complaint. This patient should go to the medical clinic ASAP and quite possibly needs an urgent referral to an eye specialist. There are many examples of eye complaints that arise as a result of a medical condition. Examples include the inmate with sudden vision decrease in one eye, who in this case of mine had a retinal detachment, a diabetic who is having decreased vision as a complication of diabetes, or an elderly inmate with vision disturbances and headaches as a result of glaucoma or temporal arterititis. Individuals at high risk for medical complications of the eye include the elderly, those with chronic debilitating diseases like diabetes, and those taking anticoagulants. Correctional medical staff should have a basic understanding of the important medical disorders of the eye.
“My yearly eye exam is overdue. Please schedule me to see the eye doctor.”
The question here is how often do you do screening eye exams on patients who have no specific eye complaints? It is important to remember that there are two entirely different screening eye exams that can be performed. The first is a refractory exam, consisting of visual acuity (like reading a Snellen chart) and an evaluation of the eye using an auto refractor. The point of this evaluation is to prescribe corrective lenses. We’ll call this the Refractory Exam.
The second type of routine screening is the medical eye exam, which, of course, checks for diseases of the eye. The medical eye exam consists, among other things, of tonometry to measure eyeball pressure and pupil dilatation to allow detailed evaluation of the retina. These two examinations can be done at the same time, but often are not.
One problem with setting up a program for routine eye exams in corrections is that there is no clear-cut community standard for these exams. Different insurance policies authorize different exam periods. For example, really good health insurance will pay for a complete eye exam yearly for life. But many insurance policies have the eye exam as optional or omit it entirely. Idaho Medicaid used to pay for yearly eye exams but that benefit was cut a couple of years ago. There is only one guideline I am aware of. The American Optometry Association has written a guideline that says children younger than 18 should have a yearly refractory eye exam. From 18 to 40, the AOA recommends every 2 years. After age 40, due to age related diseases of the eye, the AOA says yearly eye exams should recommence. The AOA exams are comprehensive, meaning they include both refractory and medical screening. As far as I am aware, there have been no studies of the efficacy of such a rigorous schedule of eye exams on overall health as there have been for mammograms, PAP smears and prostate exams, for example. And our population is different from the population the AOA based this guideline one. Our patients don’t drive, for one example.
Putting all of this together, it seems to make a difference whether your facility is a Juvenile Detention Center, a jail or a prison. In jails, whether juvenile or adult, no routine eye refractory exams need be ordered until the inmate has been incarcerated for one year unless there is a medical reason for an earlier eye exam, such as diabetes, hypertension, or severely impaired vision. In prisons, a scheduled eye exam of inmates younger than 40-50 every 2-3 years seems reasonable to me. Yearly eye exams of inmates in this age group seems excessive (even the AOA does not recommend exams that often!).
The main problem of patients older than 40 is the loss of near vision (as I myself have learned). Keep those reading glasses available! Patients older than 40 with preexisting health conditions that can affect the eye should probably get a yearly eye exam. Whether healthy patients in their 40s without complaints need a yearly exam seems debatable to me.
Since the incidence of serious eye pathology goes up with age, older patients should again receive yearly medical eye exams, even if they are healthy and without complaint. I do not know what the optimal age for this transition is, however. 40? 50? 55? 60? Make your choice!
Does your facility have an effective policy for eye exams and eyeglass prescriptions that works? Please share! How can you practice good medicine and be cost-effective at the same time?