Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1

The Principle of Fairness

In my opinion, the first and most important difference between Correctional Medicine and outside medicine is that in Corrections, we must be fair and uniform in our treatment of inmates. We need to treat all of our patients the same. I call this the “Principle of Fairness.” This is very different than the way medicine is practiced outside of jails.

Outside medicine is not fair at all. Examples of this are easy to point out.

The first is that that what kind of medicine you get in the outside world depends on how wealthy you are and what quality of medical insurance you have. Walk into (almost) any doctor’s office or clinic in the US, and the very first procedure performed will be the “Wallet Biopsy.” If you have no insurance or inferior insurance and no money, you very likely will be turned away. With no insurance, you often cannot afford to buy your prescribed medications.

I ran into this dilemma repeatedly back in the days when I was an Emergency Physician. I would discharge an uninsured patient with instructions to follow up with a physician in the community, only to learn later that the physician had refused to see them without cash up front. Variations of that happened more times than I could count. Often, there was no one in my community who would see an indigent ER patient.

This dilemma continues to happen to me in jail clinics! I once had a patient arrive at the jail with Type I diabetes. We were able to get him under control while he was incarcerated, but upon his release, despite numerous phone calls, no local practitioner was willing to continue to take care of him without cash up front—which the patient did not have.

I understand this. Outside medical practice is a business and like any business, if a medical practice were to treat patients for free, it will not remain in business for long. Also, there are federal rules that say that if a practitioner offers discounts to one patient, she must also offer that discount to Medicare and Medicaid patients. So even if physicians are willing to treat some patients pro bono, it is illegal to do so.

I have been talking here about uninsured patients, but even patients with lesser quality insurance are discriminated against by some practitioners. I know of physicians who refuse to accept Medicare and Medicaid. You could be a patient of a certain doctor I know for 30 years, but the second you turn 65, you will receive a letter discharging you from the practice. True!

Also, some practitioners refuse to accept negotiated price schedules from insurance companies and so are not “preferred providers.” This, of course, means that their patients may not see those physicians without up front cash payments.

In the end, outside medicine is, well, not fair! The “Haves” can get any medical care they need–or want–while the “Have Nots” must accept limited choices or nothing at all.

That is–unless they go to jail or prison!

As we in the correctional medicine business know, incarcerated inmates have a constitutional guarantee to medical care. They are the only group of US residents I am aware of that have this guarantee. Note that I used the word “US residents” rather than “US citizens,” because the right of an incarcerated inmate to medical care applies to everyone who is incarcerated, whether the inmate is a citizen of the United States or is an illegal immigrant.

The right of inmates to necessary medical care was established in 1976 in the landmark Estelle v. Gamble Supreme Court decision. In this landmark decision, the Supreme Court held that:

“the deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’…proscribed by the Eighth Amendment.”

Memorize this line!

Further legal decisions have expanded upon what is meant by this phrase, but in the end, all jails and prisons must provide necessary medical, mental health and dental care to their incarcerated inmates.

We don’t get to do “wallet biopsies.” Everybody in our correctional institutions can request to be seen by a practitioner. Everyone is assessed and treated for medical problems, both big like cancer and small like athlete’s foot. Both acute, like a sprained ankle and chronic, like hypertension.

In fact, a big part of our job, especially in prisons, is to make sure that no one with hypertension or diabetes, say, falls through the cracks and is forgotten. We call that “Chronic Care.” On the outside, if a patient does not show up for his scheduled yearly check up, the doctor’s office might send him a reminder card, but other than that, too bad.

But in a well run prison, such a patient would not be forgotten. If necessary, medical will send a correctional officer to his housing dorm to bring him in for his appointment. He can refuse, but it usually has to be in person and in writing.

Medical Needs versus Medical Wants

A final issue of fairness between Outside Medicine and Correctional Medicine is this: On the outside, there is little distinction made between medical needs and medical wants. In fact, some of the most lucrative medical practices are devoted to wants, like aesthetic surgery. Most of Direct to Consumer advertising of drugs that we see on television is (in my opinion) an attempt to make people want drugs that they don’t need.

In jails and prisons, inmates have a right to treatment of their medical needs, but not to their medical wants. A big part of what correctional practitioners do is sort out needs versus wants. One obvious example that will resonate with all correctional providers is the inevitable request by inmates for a “double mattress.” This is a classic “Want” but certainly not a medical “Need.” In fact, this is not a medical issue at all, in my opinion.

The Principle of Fairness is important in any consideration of a medical Want. You cannot give any medical service to one inmate and deny that service to others. That creates “special” inmates who get special privileges from medical. If you give one inmate a medical service, via the Principle of Fairness, you are obligated to give every inmate with similar presentation the same service.

If a correctional practitioner approves a double mattress for an inmate who, say, complains of chronic low back pain, she is bound to approve a double mattress for every inmate with a similar complaint.

The consideration of Fairness underlies everything we do in correctional medicine. It is hard to overstate how important it is. There is not a day that goes by in my Correctional Medicine practice where Fairness does not come up.

What is your opinion about the Principle of Fairness in corrections? Do you think outside medicine is fair? Is medicine in your facility fair? Please comment!

As always, this JailMedicine post presents my opinions. I could be wrong!

13 thoughts on “Correctional Medicine: The Principle of Fairness

  1. We recently completed an IGA (inter-governmental agreement) with AHCCS (Arizona Health Cost and Containment Services). This not only helps us with hospital bills if an inmate spends 24 hours or more in the hospital, but also helps us to sign up inmates for AHCCS prior to release. For example, we have an inmate being released today that has been with us for about 3 months now. He is a brittle insulin dependent diabetic that has been on insulin since age of 12. His insulin costs about $300 cash not including needles, syringes, glucometer strips, HTN meds, etc. Inmate has confirmed AHCCS insurance upon leaving the facility. Just a little bit info to further this idea – we recently received an e-mail from a law firm in Tucson stating we must offer all inmates that are being released AHCCS sign-up. This will be a big challenge.

  2. Thanks a bunch for this article on fairness and needs vs want. Is providing OTC hydrocortisone top cream to an indigent inmate and not providing it to another who has funds in their canteen fair treatment or discriminatory.

    • Hi Jude! You certainly can provide OTC hydrocortisone cream to an indigent patient. The Principle of Fairness says that you then have to offer hydrocortisone cream to every inmate with a similar presentation. If you decide to give any OTC to indigent inmates, one question to ask is whether the patient is truly indigent? Sometimes inmates will say in clinic that they are indigent, but when you check, they actually have money on their books, or else get money deposited regularly. Others truly are indigent–they never have had money on their books and likely never will. How will you define who is eligible for this service?

      Some jails have solved this problem by creating an indigent commissary. Indigent inmates (by the jail’s definition) can get certain items from the commissary like hydrocortisone cream, and Tylenol without having to go to medical. Your jail probably already has such a system set up for non-medical items like paper and pencils. You just need to add certain medical commissary items to the list. That gets you out of the loop of having to figure out who is truly indigent!

  3. Dr. Keller, your article about in and out of custody care’s focus on fairness is a good way to describe the differences. And fairness does rule our institutions. Just try giving one person something and you have many more requests for the same thing– our patients talk and compare just like we do with our neighbors.
    Thanks for this well balanced article, it would be good to give this to staff in orientation as it sets the stage for a good practice whether you are a provider or line nursing staff. Standardized care works best in our facilities with fairness based on diagnosis (need not want for sure)

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  6. I have a question. With such a high epidemic of opiate abuse and the use of methadone or suboxone to help treat addiction, what happens when someone is prescribed one of those drugs before they get sentenced? Will the jail continue to provide the medication for them or do they refuse treatment like that? I know a lot of people whose lives were saved by the use of those drugs and if they were to stop they would get extremely sick yet I’ve been told jails have refused to helped them medically. To me that sounds wrong. If you have a prescription in the free world, how could it be stopped like that in jail simply because the jail doesn’t approve treating addiction? Thank you.

    • I’ve just started in correctional nursing and find it very interesting. I too, am curious about those inmates using suboxone and/or methadone and having it acutely withdrawn upon intake. Upon further investigation, I’ve sometimes found they haven’t complied in months or years and for that I believe administration is not warranted because I agree with the philosophy of we’re a jail, not a treatment center or hospital. But, what about the one inmate that truly has been helped by suboxone? Anyone?

  7. As someone from outside the US, it is foreign, ridiculous and disgusting to hear about people being denied for money/insurance reasons. I learned a new term today – “wallet biopsy”.

    Not to mention, if you’re not wealthy, it seems you can get better treatment in a prison than being outside of one.

  8. I have family members who have been in local or regional jails for pre-trial and serving time. It is a very different world than a prison. The difference between them being a Prison held human, one who is serving a felony sentance-defined in Virginia as 12 or greater months on one charge-has far more options and treatment possibilities. Jail held humans are trested little better than police dogs. The people with the least time and less secere crimes.

    I am award of multiple cases within 25 miles where jail held humans were left without prescribed medication to the point of minor medical treaments being witheld for no reason evdn if they arrive with their meds as they content of the bottles is considered suspect. They are requried to get their meds by admisnstrative approvdd means to ensure they are in fact the proper substance. This has lead to many many preventable illnesses, relapses, psychologic distubances and more than one, organ failure and/or death.

  9. Sorry fpr the spelling errors, I am accustomed to real keyboards and these phone keyboards are annoying.

    Additionally, the worse the crime the better a person convicted of the crome will be fed and housed. Makes sense to anyone electdd, but no one else.

    As a dental technician I can also tell you who gets vastly more and better dental care.

    [Modeator-feel welcome to edit/merge my comments]

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