Correctional Managed Health Care Committee (CMHCC)
In 1993, the Texas Department of Criminal Justice (TDCJ), The University of Texas Medical Branch (UTMB) at Galveston and the Texas Tech University Health Sciences Center (TTUHSC) joined forces to form the Correctional Managed Health Care Advisory Committee (CMHCAC). Subsequently amended through refinement of its legislative authority as the Correctional Managed Health Care Committee (CMHCC), the CMHCC has developed a statewide provider network to provide medical services to TDCJ offenders. Its primary purpose is to improve access to quality health care while containing cost by maximizing the use of the state’s medical schools, securing efficiencies through improved intergovernmental collaboration and using managed care tools.
In Texas prior to the implementation of the program, costs for prison medical care had been increasing at a rate of 6% per year and represented 10 – 14% of the state prison system’s operating costs. Additionally, in response to overcrowding, Texas had embarked upon an aggressive prison construction program that would soon confine nearly 150,000 offenders. Since many new prison locations were in rural areas, the economic problems faced by rural hospitals further impacted upon the state’s ability to provide cost-effective health care. Traditional delivery systems were also strained by increased rates of infectious diseases such as HIV, Hepatitis C and tuberculosis.
From its inception the Correctional Managed Health Care program has operated as a cooperative partnership between TDCJ, UTMB and Texas Tech. This partnership is embodied in the legislation that formed the committee and included equal representation from each entity. The Correctional Managed Health Care Committee (CMHCC) is established by the provisions of Section 501, Subchapter E of the Texas Government Code. This legislation originally enacted by the 73rd Legislature and amended and re-authorized by the 76th and 83rd Legislatures in response to Sunset reviews provides the structure for the correctional health care system now in place.
This partnership significantly changed how medical care is delivered in the TDCJ. Traditionally offender health care was provided by employees of the prison system and through fee-for-service arrangements with hospital providers. These arrangements offered little incentive to control costs. Under the managed health care plan, complete medical services are provided through contracts with state medical school universities. TDCJ contracts with the UTMB and TTUHSC for the provision of health care services. The offenders for which UTMB and TTUHSC receive payment are determined by the geographic location of the prison units. TTUHSC contracts with the TDCJ for defined regions in West Texas, approximately 22% of the offenders. UTMB contracts for nearly all the remaining defined geographic regions; approximately 78% of the offenders. The TDCJ Health Services Division retains the functions of preventive medicine, offender Step II medical grievances, health services operational reviews, health services quality monitoring, and coordination of offender medical transfers.
UTMB and Texas Tech are responsible for the provision of medically necessary health care services. Responsibilities include recruiting and hiring health care personnel to staff the prison medical departments, diagnosing prisoners’ health problems, and providing treatment or making referrals to specialists. These services include unit primary care services, all specialty care services, all pharmaceuticals, community provider outpatient and ancillary services, and all in-patient hospital services. Both UTMB and TTUHSC enter into subcontracts with community providers to provide locally based services when they determine such action is warranted.
Beginning January 1, 1996, UTMB and TTUHSC assumed operational responsibilities for all TDCJ mental health services in their respective university sectors. All psychiatrists and former TDCJ mental health staff were transitioned to the university systems.
These arrangements provide incentives for controlling utilization and generate an increased interest in preventative care. Use of telemedicine and most recently, electronic medical record technologies also enable cost-effective access to specialty care.
The CMHC partnership has resulted in lower medical costs. It has also resulted in the establishment of a statewide network of health care providers and a uniform standard of care. While maintaining a commitment to accreditation and significantly improving access to care, the Texas State Comptroller has estimated that the correctional health care partnership saved the taxpayers of Texas at least $125 million over its first five years. It also serves as a model of intergovernmental collaboration for other states to use to manage access, quality and cost of correctional health care.
In fiscal year 2005, medical costs were about $6.80 per offender per day. In FY 1993, prior to the implementation of the managed health care system, those costs were $5.99 per offender per day. On a per capita basis this represents an increase of about 1% per year over that time frame, compared to the 6% a year increase experienced prior to implementing the program. An independent actuarial review conducted in October 2002 found that correctional health care costs are approximately 44% lower than comparably adjusted public sector HMO’s in Texas (when age, population and patient acuity factors are taken into account).
At the same time, health care provider vacancy rates dropped significantly; the average number of days spent waiting for a specialty clinic appointment dropped by over 50%; access to care indicators show marked improvement and every TDCJ health care facility has received national accreditation. Since the implementation of the managed care system, and based on an independent review of medical records conducted by the Texas State Auditor in 1998, access to care compliance improved 27.7%, clinical encounter compliance increased by 35.7% and most dramatically, chronic care compliance rose 158%. In all, twenty-two individual performance indicators showed statistically significant gains.
The managed care partnership has also implemented a series of disease management guidelines. A retrospective review conducted in FY2002 indicates that overall compliance with key disease indicators rose from 40.1% in 1995 to 91.3% in 2001. That same review noted improvements in health outcomes including a 17% decrease in fasting glucose values among insulin dependent diabetics, a 19% decrease in the LDL cholesterol values of patients with hyperlipidemia and a 114% increase in the number of hypertensive patients with controlled blood pressures.
It is also important to note that these positive results were obtained at the same time that the correctional population served more than doubled.
In 1995, the CMHCAC partnership was awarded Special Mention by the National Managed Health Care Congress in their annual Astra Merck/NMHCC Partnership Award program. Even though the program traditionally focused on private sector partnerships, the judges noted that the TDCJ-CMHCAC partnership “does reflect the innovative spirit celebrated by the awards, and therefore grabbed our attention as deserving of a special mention.”
In 1996, the correctional pharmacy program was awarded the “Innovative Practice Award” by the Texas Society of Health-Systems Pharmacists.
In 1997, the James Byrd Diagnostic Unit in Huntsville was selected from over 400 nationally accredited facilities nationwide as the National Commission on Correctional Health Care’s “Facility of the Year.” Four of the top five finalists selected for the award were Texas facilities.
In 1998, the Texas correctional health care program was recognized by the American Correctional Association as one of the nation’s “Best Practices.”
In 1999, the federal court that for years had oversight of Texas prisons released the medical care issues from federal supervision recognizing that “there can be no doubt that the vast improvements in TDC’s provision of medical and psychiatric care to inmates have been made…there are now two of the state’s finest medical teaching institutions, The University of Texas Medical Branch at Galveston and Texas Tech University Health Sciences Center, giving treatment to inmates.”
In June of 2001, the federal court relinquished the State of Texas from all remaining federal oversight, including the issue of providing mental health care services to offenders in administrative segregation.
The CMHCC partners believe that the results of their cooperative venture represent long-term benefits to the state and each respective partner. The partnership emphasizes “win-win” scenarios where the motivations for the participation of each partner are recognized and addressed. The criminal justice agency is seeking quality, cost-effective health services. The universities are seeking teaching and placement opportunities as well as financial support. The participating hospitals are seeking financial stability. By understanding these motivating factors and integrating them into the work of the partnership, a successful venture has been formed.
Historical Key Events In Committee History
Key events relating to the development of the CMHCC are summarized by the timeline below:
- “Against the Grain”, January 1993 – Texas Performance Review recommends formation of managed health care structure for TDCJ health care system.
- 73rd Legislature, 1993 – Senate Bill 378 passed establishing the Managed Health Care Advisory Committee (MHCAC).
- “Health Services Review”, September 1993 – State Auditor releases report on TDCJ Health Care Services that endorses managed health care concepts.
- August 1993 – Organizational meeting of the MHCAC is held.
- September 1993 – February 1994 – MHCAC and university providers develop transition plans.
- February 1994 – September 1994 – Transition to university managed system under the MHCAC authority begins.
- “Behind the Walls”, April 1994 – Texas Performance Review, in a comprehensive review of TDCJ, recommends that MHCAC conduct a staffing analysis.
- September 1994 – Transition to university management completed.
- December 1994 – MHCAC adopts staffing analysis guidelines.
- December 1994 – House Corrections Committee completes interim charge study of implementation of the correctional managed health care system and reports positively to the 74th Legislature, recommending continuing monitoring.
- 74th Legislature, 1995 – HB 1567 amends MHCAC statutory authority, charging name to reflect correctional mission (becoming the Correctional Managed Health Care Advisory Committee, CMHCAC), extending authority of the committee to contract with other jurisdictions and authorizing the universities to report ERS benefits in accordance with intent to protect transitioned employee benefits.
- 74th Legislature, 1995 - General Appropriations Act consolidates prison hospital and prison health services budgets into one strategy for managed health care. University appropriations include rider prohibiting other funds to be used for offender health care.
- January 1996 – CMHCAC and TDCJ agree to proceed with transition of psychiatric services to the correctional managed care program.
- March 1996 – The State of Texas files a motion to vacate the provisions of the Final Judgment in the Ruiz litigation. (The Final Judgment was entered into by the State and the Ruiz plaintiffs in August of 1992 which vacated hundreds of earlier specific requirements and replaced it with continuing permanent injunctive orders on eight substantive areas, including health care).
- The U.S. Congress passes the Prison Litigation Reform Act (PLRA).
- October 1996 – Office of the State Auditor initiates a comprehensive review of the correctional health care system (estimated completion October 1997).
- December 1996 – House Corrections Committee completes second interim charge study continuing its review of the implementation process and reports positive finding to the 75th Legislature.
- May 1997 – CMHCAC added to Sunset Advisory Commission review cycle to coincide with review of the Texas Department of Criminal Justice.
- July 1997 – The Fifth Circuit rules on motions and discovery issues in pending motion to vacate the Final Judgment. Plaintiffs attorneys and experts afforded access to prison facilities and records for various inspection and discovery purposes.
- Fall 1997 – CMHCAC and TDCJ conduct comprehensive review and updating of HIV related policies and practices.
- January 1998-1998 – Office of the State Auditor issues SAO Report Number 98-013 noting that the system had achieved the overall objective of controlling the increasing costs of providing health care to offenders and recommended a number of areas of potential improvement/and or legislative clarification for consideration.
- December 1998 – CMHCAC initiates comprehensive examination of issues related to the management of Hepatitis C.
- January 1999 – Federal District Judge William W. Justice begins hearing on State’s motion to vacate the Ruiz Final Judgment. Extensive medical and mental health testimony and evidence is presented before the court.
- March 1999 – Judge Justice issues Memorandum Opinion and Order on Motion to Vacate, denying State’s Motion due to findings in the areas of conditions of confinement in administrative segregation, safety for assaulted and abused inmates, and excessive use of force. The Court’s Orders did however relieve the State of the obligation under the Final Judgment relating to health services. These findings and orders have been appealed.
- May 1999 – Recommendations of the Sunset Advisory Commission are adopted by the Legislature in Senate Bill 371. Name of the Committee is changed to the Correctional Managed Health Care Committee and public member participation is added.
- May 2001 – The CMHCC enabling legislation was amended to require reasonable efforts to participate in the purchase of prescription drugs under Section 340B, Public Health Services Act (42 USC Section 256b)
- April 2002 – UTMB becomes certified by the federal authorities to access 340B drug pricing for prison inmates confined in facilities operated by UTMB, resulting in significant reductions in overall CMHCC drug costs.
- February 2003 – All agencies are asked to develop budget reductions geared to address State’s projected overall funding shortfall. During FY 2003, the CMHCC, in conjunction with the university providers, implement budget reductions totaling $8.1M. To implement these measures, a statewide reduction in force of almost 400 health care staff takes place and resulted in significant changes in the hours of health care coverage at many facilities.
- May 2003 – Sunset date for CMHCC was extended to 2011 to coincide with the Sunset Commission evaluation of TDCJ.
- November 2004 – The State Auditor’s Office released a report on the management of contracts by the CMHCC calling for significant improvements in financial reporting and monitoring of the contracts with the university providers.
- January-May 2005 – 79th Legislature: Working with the Legislative appropriations process and the SAO, strategies are developed to address concerns raised by the audit report on management of contracts. Additionally, supplemental appropriations for FY 2004-2005 are approved and appropriations for the FY 2006-2007 biennium are increased. The Sunset review date for TDCJ and the CMHCC are moved forward to 2007.
- October 2006 – Sunset Commission Staff Report issued following a comprehensive review by the Sunset staff outlining recommendations to update CMHCC’s enabling legislation and improve public access to information about the program.
- October 2006 – The State Auditor releases a report on the costs of the State’s Correctional Managed Health Care program finding that the university provider financial reports are supported by each institutions accounting system, that the methods used to account for and report the cost of care are reasonable and that the CMHCC had made changes in its operations to address issues raised in the November 2004 SAO report.
- December 2006 – Sunset Advisory Commission formally adopts staff recommendations relating to the correctional health care program.
- March 2007 – The State Auditor issues an audit report on Correctional Managed Health Care Funding Requirements noting that the projected deficit reported by the CMHCC had been reduced since originally projected; that UTMB’s projected deficit should be adjusted to account for discrepancies identified by the auditors; and that the CMHCC properly complied with two appropriation riders reviewed by the State Auditor’s Office.
- May 2007 – The 80th Legislature adopts SB 909 reauthorizing the CMHCC and enacting the recommendations of the Sunset Advisory Commission.
- February 2011 – State Audit Report on correctional Managed Health Care at the University of Texas Medical Branch at Galveston, SAO Report #11-019.
- February 2011 – State Audit Report on the Correctional Managed Health Care at the Texas Tech University Health Sciences Center, SAO Report #11-019.
- May 2013 – The 83rd Legislature adopts SB 213 reauthorizing the CMHCC and enacting the recommendations of the Sunset Advisory Commission.
- May 2013 – Senate Bill 1, 83rd Legislature, Regular Session, Article V, Rider 50 prohibits any of the funds appropriated for correctional managed health care to be used for payment of salaries, operating expenses or travel expenses for staff of the CMHCC.
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