Last week, I counted down the five most popular articles from JailMedicine’s first six months. This week, I would like to revisit my own personal favorite post. I don’t have very many really good ideas—but this is one of them: You Need a Medical Commissary in Your Facility!
To recap, I used the example of an inmate who has heartburn. Outside of jail, he uses Zantac, which he simply buys at the store. Inside of the jail, it is much different. All facilities are different, but to use a typical example, the inmate has to put in a request for medical services. He pays $5.00 to submit the request. He then is seen a couple of days later in the medical clinic and invariably receives a prescription for Zantac. (Would you say no to a patient like this complaining of heartburn? I wouldn’t). The inmate also has to pay $5.00 for the prescription.
Total cost in money for the patient: $10.00. Total cost in time for the patient: a couple of days. Typically, the prescription is written for 1-3 months, after which time, the inmate has to go through the whole process all over again.
Total cost for the jail medical system is 1-2 hours of time divided between the nurses who triage the request and take vitals at clinic and the practitioner (or nurse) who sees the patient in clinic and writes the prescription, the pharmacy who fills the prescription and maybe the security staff who escort the patient to the appointments.
It would be so much simpler and less expensive in time and money to just put OTC Zantac on the commissary and let the inmate buy it directly without having to use the medical system. The whole medical visit is basically a complicated rubber stamp of approval for the Zantac. And remember, every minute the medical staff is spending “rubber stamping” such OTC requests is a minute they are not spending with sicker, needier patients.
Multiply this encounter by all of the inmates requesting any OTC medication in jail or prison: Not just Zantac, but omeprazole, ibuprofen, Claritin, acne medications, steroid cream, and on and on. We are talking about a substantial outlay of time and effort getting inmates access to medications they could get on their own on the outside.
It seems like such a great idea that it is practically a no-brainer.
The Ada County Jail in Boise, Idaho is one jail that has implemented nearly the full contingent of OTC products I listed in my original article. The program has been running for several months and even includes an indigent commissary program, where truly indigent inmates can obtain certain OTC medications without having to go through the medical clinic. The program has been a major success. More details about the program in a future article.
Getting the medical OTC commissary idea implemented in other jails has not been easy. I myself have been unsuccessful in getting a medical commissary program started in the majority of the jails that I supervise. Why has this very good idea been so hard to implement?
Would a Medical Commissary Program Be Profitable?
The main obstacle has been the commissary companies themselves. They sometimes do carry a limited few OTC medical items, like antacids, in their commissaries. But when presented with the idea of expanding the jail commissary to include other OTC products commonly found at your corner drugstore, the commissary companies (or at least the person representing the company at the jails) has invariably said “No.” Flat “No.” The reason given is usually that the company will not make a profit on the medical items—or at least not enough profit to justify the effort of stocking the item. I have heard this excuse over and over.
I personally do not believe that this is true. Drug stores, grocery stores and even gas stations make money selling OTC medical products. Why would it be any different in jails? Such items may not be as roaringly profitable as Ramen noodles, but I suspect they would sell. They do in Ada County (which, by the way, does commissary internally and so no outside company was involved).
However, even if it were correct that OTC medical items would not be profitable, it seems to me that this excuse misses the point. The commissary company has been hired to serve the needs of the jail. The jail and the inmates themselves would benefit greatly if a medical commissary program were implemented. The jail would save time and money. The inmates would save time and money. The jail does not exist to serve the needs of the commissary company; rather, the company is hired to serve the needs of the jail. A medical commissary program is one way to do this.
This point evidently needs to be hammered home with the commissary companies.
The best way to do this is for the jail administration to insist. That is exactly what we are doing at the Bonneville County Jail in Idaho Falls. We are writing an RFP for commissary services that will require the company to have a medical commissary program with the specific items I mentioned in my article. Certain commissary companies have hinted that they may not respond to an RFP with such a requirement. We’ll see. I suspect that they will. At least one national company has said, “No problem!”
I personally think that the commissary company that first develops and markets a good medical commissary program to correctional facilities will have an instant marketing edge over their rivals.
Have you considered developing a full commissary program at your facility? Have you run into any obstacles? Please comment!
We have implemented a medical commissary program in the Davis County Jail and it has been quite successful. We did not have any problem getting our Commissary provider to allow and order the OTC meds we wanted and they not only service our jail but also provide commissary for 4 other jails that they fill the orders for right here in the Davis County Jail. They are a national commissary company formerly known as Canteen and now have changed their name to Trinity Services. They also cover Idaho. Some OTC items are quite profitable for them. When we started the program I went to our commissary rep and told her what items we wanted to sell and gave her my providers and vendor contacts as to where she could purchase the items then let her set the prices. We added some of those items to an Indigent Commissary items that an inmate can only get from a nurse and we pay for those items and fill them ourselves. Commissary does not fill any OTC meds for indigent inmates.
I am not surprised, James, that you are ahead of the game already. The Davis County jail has a particularly fine medical program. In fact, I have instituted in my jails many of the things that I observed at Davis Co!
What keeps inmates from stocking up meds and then taking an overdose of Tylenol or Ibuprofen? Is there a higher incident of suicide attempts, overdoses with those jails that have it easily available? Indigent inmates, what keeps them from using product as jail money for other food, commissary and etc… What are the legal liability of Medical staff in these situations? Just questions that I have thought about, when thinking about the pros and cons for our jail.
Ibuprofen is pretty safe–it would be very hard to kill yourself with ibuprofen unless you drowned in it. Tylenol you can hurt yourself with. The toxic dose is 140mg per kg, which for an average male, would be around 30 tablets. So there is an obligation to have some program in place to prevent hoarding. But not every jail that allows easy access to Tylenol looks specifically for Tylenol hoarding, over and above routine efforts to prevent any kind of hoarding. Fortunately, Tylenol has a reputation of being weak and safe by the lay public, including inmates, so they usually do not choose Tylenol to overdose on. I am not aware of any correctional facility that has dealt with an attempt, successful or other wise, to OD on Tylenol. There may be one, but I do not know about it.
I have seen different positions on Tylenol in different jails. Jail #1 allows inmates to get Tylenol directly from the deputies, who carry it around in their pockets. Jail #2 has Tylenol on the commissary bu allows only 15 pills a month to be purchased. Jail #3 has Tylenol on the commissary, but after it is purchased, it is dispensed from the med cart. And there are others.
What keeps inmates from using these items as barter in the inmate black market? Nothing, I guess, as long as they don’t get caught (at which point, their indigent commissary privilege is revoked). But that is why (IMO) the medical commissary should not contain abusable and/or highly desirable OTC meds like: Benadryl, dextromethorphan, or pseudoephedrine. More on the indigent commissary program in a future post.
What is the legal liability of medical staff? The attorneys at my jails where such a program is in place have not foreseen significant legal liability. After all, the community “standard of care” is to allow people to purchase OTC medications without any medical supervision. But, of course, you should check with your facility’s attorney.
The essence of this is too correct! And, cannot understand why the jail would not fully support your recommendations. Here are some additional thoughts:
1. If the jail has a co-pay system ‘medical’ items are really a necessity
2. When the inmate seeks these items from ‘Medical’ a liability can be incurred
a. If ‘given’ by the nurse from the cart w/o documentation – any bad event is a disaster
b. If documented it chews up lots of time
3. Hygiene items should be either provided by the jail – shaving cream, soap, denture cream, contact lens solution etc. – or available through commissary
4. A concern is that if it is in the commissary – example Ibuprofen:
a. One of my tools / steps is removed – ‘I’ve been getting that from the commissary for weeks and it don’t work’
b. Duplication of medicine given from ‘medical’ – NSAIDS etc.
5. One other thought – I hate ‘pepto’ – bad stuff
Good comments, all, Al. I especially like the documentation issue that you bring up.
I also dislike Peptobismol and did not include it on my medical commissary. Nor do I personally ever prescribe it.
I have not found the “I’ve already tried it” excuse to be a problem. I have a set speech in which I tell patients that there are basically only three medications for the direct treatment of pain–inside of jail or out. Those three are Tylenol, ibuprofen (and the drugs like it) and narcotics. And then I say, as a strong general rule, we don’t use narcotics in jails for chronic pain. So we are stuck with Tylenol/ibuprofen.
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