This is an important fact that I have learned from many years working in prisons and jails: Most correctional practitioners do not understand how Utilization Management in a prison system works. They misunderstand what the goal of the UM process is. They misunderstand the process of submitting requests. And they misunderstand how decisions are made. It took me a full three years of working in a prison system before I wrapped my head around how UM was supposed to function. This is because UM within a correctional system is fundamentally different than UM in the outside world and also new incoming correctional practitioners are not taught how prison Utilization Management works or how to make UM requests properly.
To show how a prison is different than Utilization Management in a typical Health Maintenance Organization (HMO) in the outside world, let’s say that I am a primary care practitioner in the community who wants to order an MRI on one of my patients. As we all know from long experience, I can’t just order the MRI. I have to get it pre-authorized. To do that, I have to submit paperwork to the patient’s insurance company explaining why I want to do the procedure. Someone will review my request, but I will have no idea who this person is or what their qualifications are. The reviewer could be a physician, or it could be a nurse referring to UM guidelines. I just don’t know and never will. Whoever that person is, they will either approve payment for the procedure or deny it.
Notice several important things about this interaction:
1. I do not know the person reviewing the request I sent in. They do not know me.
2. If the UM reviewer denies the request, that does not mean I can’t do the procedure—it just means that the insurance company will not pay for it. The patient can still have the procedure done if they want to pay for it out of their own pocket.
3. If I disagree with a UM denial, I cannot pick up a phone and call the individual who made that decision to ask “What were you thinking?” Instead, I would have to write a formal written appeal. In fact, all communications in a typical HMO must be formally written.
4. The UM reviewer (whoever that might be) does not comment on my case other than to approve or deny the request I made. They never say, for example, “What are you thinking? Read the literature! Instead of ordering an MRI, you ought to do a CT!” Utilization Management within an HMO is not a friendly collaboration between colleagues. Instead, it is an impersonal request for payment. It’s as impersonal as using Paypal for an online purchase.
Now consider the identical case within a prison. I am still asking for the same MRI. Even though the prison process is called by the same name as it is in an HMO–Utilization Management–correctional UM is an entirely different animal. First, if I again am the Primary Care Practitioner at the site requesting an MRI, I know the physician who is going to review my request. We probably communicate all the time in other matters, such as committee meetings, site visits, etc. Shoot, we may have had beers together after a conference!
Second, I know that the physician who reviews the case will not simply “deny” the request. If she does not approve the request, she must instead send back an “Alternative Treatment Plan” (ATP), describing what she thinks I should do instead of an MRI. In other words, the process has become a discussion about the proper care to be provided to this particular patient. We are, in fact, collaborating.
As I mentioned before, there is no collaboration in an HMO. There is only an impersonal “yes-or-no” question of payment. By contrast, in a prison, I am really asking my colleague “What do you think about his case? Should I do an MRI?” The answer could be “Great idea! Go ahead.” The answer could also be “I don’t think so. Here are my thoughts in an alternative treatment plan. Let’s talk about this case.”
At this point, the question is how to continue the discussion. In an HMO, if I want to appeal a denial (the only way to continue any discussion of a particular case), I would have to write a formal appeal. And the only answer I can expect is another “approved” or “denied” answer. In a prison, again, everything is different. The person who sent me the alternative treatment plan is my colleague. What is the best way to communicate with her?
Unfortunately, prison UM systems are sometimes modeled on the HMO model and primary care practitioners are expected to write formal appeals just as they would on the outside. In my opinion, this is crazy! This is my colleague, not an unknown bureaucrat. The best way to communicate with a colleague in the modern world is not via a letter! Instead, the best way to collaborate on this case would be to pick up a telephone! Alternatively, I could send an email, write a text or walk down the hallway to her office. Any of these will be faster and more efficient than writing out an appeal form.
It’s just a short distance from this to the next insight into prison Utilization Management–if I know that a request for an MRI has to go through the UM system and that it will be reviewed there by my colleague, why not pick up the phone and discuss the case with her before I fill out the initial UM form? This will save me time if my request is eventually going to be denied, since I won’t have to fill out all the paperwork. It will even save me time if my request is going to be approved. Talking is simply the most efficient way to communicate with someone I know well.
So why don’t prison practitioners do it this way? The answer is simple. They all came to prison medicine from the outside and are familiar and practiced in how UM works in an HMO. No one has pointed out how different things are in a prison. We should change this.
An earlier version of this article first appeared in CorrDocs Winter 2018
As always, what I have written here is my opinion based on my training, research and personal experience. I could be wrong!
Another great article. If the prison UM process occurs they way you initially describe it, it can be great. When it doesn’t work that way, it is a nightmare. Several things to consider:
1.You need an approving physician who is up to date and well-versed in medicine generally, as well as in the finer points of correctional medicine. If he/she is not respected by the site providers, problems will arise.
2.There must be some requirements for the approving physician’s response, like an ATP. Simply writing “denied” is insufficient. Similarly, the providers should be required to explain why they are requesting a particular test, medicine, etc.
3.The approving physician should not have his/her hands tied financially by the state or the contract provider. This does not mean the physician does not exercise common sense.
4.The approving physician should have opportunities to meet with his/her site providers as a group, so they can discuss recurring issues and make sure they are all on the same page. The hot button examples are obvious–Hepatitis C treatment/protocol, transgender and gender dysphoric inmates, etc. However, what about the more mundane things like inmate allergy claims, requests for special footwear, requests for bottom bunks, requests for special mattresses? If inmates know that one provider will always grant requests for special footwear just to avoid controversy, this makes things harder for the other providers who make decisions based upon policy and proper medical assessment.
5.The approving physician and the providers should understand the basic concepts of “deliberate indifference” as compared to medical malpractice and what exposure they face, both professionally and financially when they are named in a lawsuit. Decisions should not be based upon fear (unless the fear is justified).
Thanks again for a great article that I am sure will generate a lot of discussion.
Thanks David. Great comments, as always! More on ATPs coming . . . JeffK
Excellent article on ATP’s. A sound ATP can stop a deliberate indifference claim right in its tracks. A bad one will make you a co-defendant.
A website glitch sent it out prematurely. A better version coming soon on the website
As you mentioned, UM programs are physician-driven in prisons. Are there any existing UM programs that are nurse driven? In jails?