Texas Correctional Managed Health Care Committee

Welcome

The Correctional Managed Health Care Committee (CMHCC) is authorized by Chapter 501, Subchapter E External Link of the Texas Government Code. The CMHCC was originally established by the 73rd Legislature in 1993 to address the rising costs and operational challenges involved in providing health care to prisoners confined in the Texas Department of Criminal Justice (TDCJ).

Organizationally, the CMHCC is composed of nine voting members and one nonvoting member as follows:

one member employed full-time by the department, and appointed by the executive director;
one member who is a physician and employed full-time by the UTMB at Galveston, appointed by the president of the medical branch;
one member who is a physician and employed full-time by the TTUHSC, appointed by the president of the university;
two public members who are physicians, each of who is employed full-time by a medical school other than UTMB or TTUHSC, appointed by the governor;
two members appointed by the governor who are licensed mental health professionals;
two members appointed by the governor who are not affiliated with the department or with any contracting entity, at least one of whom is licensed to practice medicine in this state, and
the state Medicaid director or a person employed full-time by the Health and Human Services Commission and appointed by the Medicaid director, is to serve as an ex officio non-voting member.

The CMHCC coordinates the development of statewide policies for the delivery of correctional health care and serves as a representative forum for decision making in terms of overall health care policy. CMHCC representatives are empowered by their respective organizations to represent them on health care matters and make decisions that are binding on their organizations. The shared communication, coordination, decision making, and dispute resolution roles performed by the committee are key elements to the ongoing success of the correctional health care partnership.

The correctional health care system represents a unique collaboration between the state’s prison system and two of its leading health sciences centers. This health care partnership between the Texas Department of Criminal Justice (TDCJ), Texas Tech University Health Sciences Center (TTUHSC) and the University of Texas Medical Branch (UTMB) is operated under the guidance and direction of the CMHCC. The primary purpose of the CMHCC partnership is to ensure that TDCJ inmates have access to quality health care while managing costs.

The correctional health care system represents a partnership between Texas Tech University Health Sciences Center, The University of Texas Medical Branch at Galveston and the Texas Department of Criminal Justice. Through the leadership of the CMHCC, the following shared mission, vision, values and goals are set for this partnership:

Mission

The mission of the Correctional Managed Health Care Committee is to develop a statewide managed health care plan that provides TDCJ inmates with timely access to quality health care while also controlling costs.

Vision

The CMHCC is an organization that is committed to excellence; strives to set national standards in correctional medicine; focuses on building and maintaining open communications; and, serves as a model for inter-governmental cooperation.

Core Values

Quality: The CMHCC strives to provide health care services of recognized high quality and deliver them uniformly, promptly and efficiently within the limits of appropriated resources.

Integrity: The CMHCC strives to uphold the public’s trust through ethical and accountable personal and professional behavior.

Commitment: The CMHCC is dedicated to restoring and preserving the health of TDCJ inmates.

Teamwork: The CMHCC recognizes that our mission and goals are achieved through teamwork, with each partner fully participating and contributing to the organization and sharing in its success.

Organizational Goals

Ensure Access to Care:

The CMHCC recognizes that a key challenge for correctional health care is to maintain appropriate levels of access to medically necessary health care for inmates, in the face of an unprecedented growth of the criminal justice system.

Ensure and Maintain Quality of Care:

The CMHCC is committed to a program of continuous improvement that assures the services delivered are of high quality and consistent with community standards.

Manage Costs:

The CMHCC is dedicated to the development of initiatives to control the cost of delivering health care, to the extent possible, while remaining loyal to the goals of ensuring access to quality health care. The CMHCC works to anticipate changes in standards of care or demographics which may modify resource needs.

Background

The Texas Correctional Managed Health Care innovative partnership exemplifies the success possible by redefining traditional roles. It represents a unique collaboration between the state’s prison system, two leading health science centers, and a number of community hospitals.

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 inmates. 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.

Development/Design

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.

Implementation

This partnership significantly changed how medical care is delivered in the TDCJ. Traditionally inmate 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 inmates 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 inmates. UTMB contracts for nearly all the remaining defined geographic regions; approximately 78% of the inmates. The TDCJ Health Services Division retains the functions of public health, inmate Step II medical grievances, operating the family hotline, health services operational reviews, health services quality monitoring, and coordination of inmate 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.

Program Recognitions

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 inmates in administrative segregation.

Conclusion

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.

Description of Functional Responsibilities

To accomplish the mission of the Correctional Managed Health Care Committee (CMHCC), the partners have agreed to the assignment of various functional responsibilities to each of the partner agencies. The following narrative descriptions are intended to further clarify the roles and responsibilities of the Correctional Managed Health Care partners. The mission of the Correctional Managed Health Care Committee is to develop a statewide managed health care plan that provides TDCJ inmates with timely access to quality health care while also controlling costs.

By sharing functional duties, the expertise of each partner contributes to a stronger delivery system and avoids unnecessary duplication of resources. Delineation of these responsibilities facilitates information sharing and increases understanding of the lines of communication. The fulfillment of individual responsibilities is assigned to the individual partner’s management team and remains under the oversight of the respective Executive Director or University President and that partner’s governing board. Collectively, the CMHCC, like TDCJ and the universities are responsible to the Legislature and Governor’s Office. The CMHCC is also subject to the same oversight from the State Comptroller, State Auditor, and the Legislative and Governor’s Budget Offices.

Each assigned function is briefly described below.

CMHCC Responsibilities

Statutory Duties: The CMHCC performs specific duties as outlined in Chapter 501, Subchapter E, Texas Government Code.

Legislative and Legal Coordination: The TDCJ and the CMHCC both serve as points of contact for legislative matters and coordination of statewide legal issues.

Monitoring Coordination: The CMHCC ensures that monitoring processes are in place to measure, evaluate, and report on activities of the health care system.

Cost Containment Initiatives: In conjunction with each of the partners, the CMHCC coordinates individual and joint initiatives for cost reduction strategies. A key element of the CMHCC role in this area is to facilitate sharing of innovations developed within each sector.

Coordination of Joint Committees: The CMHCC ensures central coordination, partner representation and direction to a number of standing and ad hoc joint committees that provide coordination of necessary services on a statewide basis. Joint committees address such issues as statewide policy development, review and approval; joint peer review activities; statewide pharmacy and therapeutics issues; and coordination of specialized clinical focus groups.

Alternative Dispute Resolution: The CMHCC serves as a dispute resolution forum in the event of a disagreement relating to inmate health care services between the department and the health care providers or contracting entities.

Public Accessibility: The CMHCC maintains a formal website to make CMHCC information more accessible to the public.

Development of Services/Benefit Plan: the CMHCC serves as the final authority on determination of services to be provided to the inmate population. These services are generally outlined in the contractual documents and in policy statements approved by the CMHCC.

TDCJ Business and Finance Division Responsibilities

Fiscal Oversight: The TDCJ’s Business and Finance Division’s staff monitor the overall financial status of the correctional health care program, work cooperatively with each partner agency in developing system-wide reporting mechanisms, track and evaluate cost trends and project future needs.

Budget Formulation/Submission: The TDCJ Business and Finance Division staff work cooperatively with each partner agency to formulate budget submissions for the health care program.

Financial Monitoring: The TDCJ Business and Finance Division conducts financial monitoring of the correctional managed health care program; and may contract with an individual for financial consulting services including actuarially studies.

TDCJ Health Services Division Responsibilities

Monitoring/Central Reporting: TDCJ Health Services staff provides monitoring activities related to investigating medical grievances, ensuring access to medical care, conducting periodic operational reviews of medical care provide at its units and cooperating with the university providers in monitoring quality of care. Staff also report on the results of those monitoring activities.

Accreditation Tracking: TDCJ staff track the progress of each unit through the accreditation process and provide that information to management for follow-up necessary.

Policies/Standards: the TDCJ Division Director for Health Services serves as the final approval authority on all statewide health care policies. Such policies are developed in accordance with procedures implemented by the Joint Health Services Policy and Procedure Committee and are approved by the respective university medical directors.

Operational Reviews: As a part of the monitoring program, TDCJ staff conduct operational reviews to evaluate the health care delivery systems in place at each facility. This process is based on assessing compliance with the accreditation standards of the American Correctional Association (ACA), statewide policies and applicable laws. A review and corrective action plan process is required from the provider management team in response to identified deficiencies.

Public Health: the Office of Public Health section in the Health Services Division is responsible for coordination of the statewide Infection Control Committee. The Office of Public Health staff provide education, orientation and training programs to Infection Control nurses (i.e., public health) statewide. This staff establishes, maintains and monitors statewide inmate data bases for HIV/AIDS, TB, hepatitis, syphilis, and sexually transmitted infections. It serves as the central point of contact for reporting purposes to the Texas Department of State Health Services (DSHS) and other applicable state and federal agencies.

Grievance and Correspondence Tracking: the Patient Liaison Office provides tracking, investigation and response to all correspondence regarding patient care issues. The Office of Professional Standards tracks, conducts inquiries and responds to Step 2, Division-level inmate medical grievances.

Research Approval: The TDCJ Director of Health Services or designee shall have the final approval for all biomedical research involving TDCJ inmates. All medical research projects will be reviewed by the Director of Health Services or designee in accordance with TDCJ Administrative Directive 02.28 (rev. 2) “TDCJ Research” and Correctional Managed Health Care Policy I-72.1 “Medical Research”. Depending on its nature and proposed methodology, such research may also be subject to review and approval through one or more of the university institutional review boards.

Quality Improvement/Quality Management (QI/QM) Coordination: the TDCJ Health Services Division provides statewide coordination of the QI/QM program. Registered Nurses provide technical assistance, collect reports of QI/QM results, analyze for trends and communicate those results system-wide.

Liaison Activities: The TDCJ Health Services Division functions as TDCJ’s single point of contact for communications related to inmate health care. This enables TDCJ departments, the CMHCC, the university providers and other contracting entities to work with a single point of contact.

TDCJ Responsibilities Involving Multiple Divisions

Legislative Coordination: The TDCJ in coordination with the CMHCC and the universities, serves as the central point of contact for legislative matters including communications with the legislature regarding the financial needs of the correctional health care system.

Contracting/Provider Network Coordination: The TDCJ develops, maintains and administers the master contracts between TDCJ and UTMB; and TDCJ and TTUHSC that establish responsibilities for the statewide provider network. The TDCJ also has statutory authority to contract with any entity to fully implement the managed health care plan.

Classification/Transportation Coordination: TDCJ Health Services Liaison staff coordinate with TDCJ classification and transportation staff to assist in ensuring that inmate patients are appropriately classified, assigned to facilities and transported consistent with their medical needs.

Emergency Coordination: the TDCJ Correctional Institutions Division, in conjunction with TDCJ Health Services, provides statewide coordination and liaison between the health care providers and TDCJ in the event of an emergency.

University Providers Responsibilities:

Utilization Management: establishing and maintaining a system for review and authorization of care to ensure that services are provided in a timely appropriate and cost-effective manner.

Provider Network Management: each university, either through its own staff, through its component or affiliated hospitals or through contractors retained by the university must ensure that a comprehensive network or providers is in place to efficiently serve the system.

Credentialing: Each university provider is responsible for ensuring that all health care providers have and maintain appropriate credentials in accordance with state and federal requirements and that processes are in place to verify and document the credentials of its staff.

Regional Operations: Each university provider is responsible for providing the management and operation of regionalized facilities and services as appropriate.

Health Care Services: Each university is responsible for providing nursing, medical, dental, and mental health services at contracted TDCJ units:
- Onsite Services: may include sick call, chronic care, infirmary care, medical record management, medication administration, health education/training and related ancillary services.
- Offsite Services: Emergency care, hospitalization, specialty physician consults, diagnostic procedures, surgeries, and emergency medical transportation.
- Pharmacy Services: medications, as prescribed by authorized providers and pharmaceutical management.
Institutional Committees/Peer Reviews: Each university provider is responsible for maintaining its own institutional committees and conducting its own internal peer review actions.

TDCJ Employee Health Services: Each university provider is responsible for providing employee health care services specified by contract including immediate medical attention to TDCJ employees injured in the line of duty, TB screening, treatment and immunizations as clinically indicated for bonafide occupational exposures.

Research Coordination: For research involving TDCJ inmates, the university providers are required to receive approval from the TDCJ Director of Health Services or designee in accordance with applicable TDCJ policies. The university providers are also responsible for obtaining approval through an Institutional Review Board which meets requirements as set forth in 45 CFR 46, revised October 1, 1999. The university providers are responsible for maintaining accurate, current and accessible records on all protocols involving inmates. The university providers are required to provide access to such records to the TDCJ Director of Health Services or designee on request.

Telemedicine: the university providers are individually responsible for the operation and implementation of telemedicine within their sectors.

Emergency Preparedness: each university provider is responsible for ensuring an emergency preparedness program is in place at each facility consistent with the ACA standards. Statewide coordination during emergencies will be provided by the TDCJ staff.

Centralized Statewide Services Provided by UTMB:

Health Records Coordination: UTMB provides statewide technical support, policy development and forms control services related to the medical records system, to include the maintenance of the medical records archives and death records.

Radiology: UTMB provides statewide liaison with the Bureau of Radiation Control, provides radiation safety services, equipment registration and coordination of related policy and procedures.

Funerals/Autopsy Services: UTMB coordinates inmate funeral/autopsy services on a statewide basis.

Medical Training: UTMB provides health-related training required for security staff during pre-service and in-service training academies for TDCJ staff. Topics include HIV (AIDS), Hepatitis, Suicide Prevention, CPR, etc.

Clinical Services: The following clinical services are provided by UTMB on a statewide basis:
- all female inmate health services
- management of inmates with solid organ transplants
- management of inmates with hemophilia
- drug therapy Hepatitis C management
- assistive disabilities services