Healthcare Behind Bars

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Class of ’75 | During his career in healthcare administration, Bruce Herdman WG’75 Gr’82 G’83 had plenty of experience helping vulnerable populations get medical care. As senior vice president for psychiatry and mental-health services at Pennsylvania Hospital, one of his duties was to make sure that adults and teens with mental-health issues got the treatment they needed. As senior vice president for Independence Blue Cross (IBC), his responsibilities included helping people on Medicaid gain access to healthcare.

But if he thought he was working with challenging populations before, they were nothing compared to those he’s dealing with now. As chief of medical operations for the Philadelphia Prison System (PPS), he’s responsible for the medical treatment of more than 8,000 inmates.

“The prison population is medically, economically, psychologically, and socially very, very disadvantaged and very needy,” says Herdman. “The average age of inmates is 29, but they are 45 years old physically, coming from an environment of poverty and drug addiction. Eighty percent of the inmates have a drug problem and a much higher rate of chronic mental-health and physical illness, and of sexually transmitted diseases, than the general population. Most receive little if any care in the community. So when they come here, they’re pretty sick.”

Furthermore, when Herdman started in 2006 (he thought he’d stay on the job for a year), healthcare expenditures for prisoners were increasing about 12 percent a year, and timeliness of care was a serious issue.

Having earned an MBA in healthcare administration, a PhD in economics, and a master’s in management from Wharton, Herdman knows his way around these issues. He has kept cost increases to less than three percent annually while improving inmates’ overall health during and sometimes even after incarceration.

The soaring costs and sluggish response-time in the prison system were largely the result of bureaucratic inefficiency. Over the years, city administrators had burdened providers with red tape that interfered with the delivery of timely services. Herdman has taken the opposite approach.

“It was very easy to improve the quality of healthcare by clearing paths to allow providers to practice medicine and not deal with bureaucracy,” he says. “It’s a matter of getting the right provider to the right patient.”

Before Herdman arrived on the scene, inmates often requested appointments with a physician to obtain services that were not medical, such as using the phones in the health center to call their families. He quickly instituted a triage system to screen out prisoners who weren’t sick. He also increased the use of nurse practitioners, who are more cost-effective than physicians, and usually just as effective medically. In fact, he says, inmates often prefer nurse practitioners and are more open with them about their problems.

As a result, inmates now receive care on a relatively timely basis. Prisoners must have an intake screening within four hours of their arrival at a detention center, and urgent referrals for behavioral health services must be handled within 24 hours.

When Herdman started, the city had no contracts with outside providers and did not have contracts with any of the city’s hospitals. Many inmates needed to see specialists, some desperately, but without contracts, making that happen was time-consuming and often frustrating for all concerned. Scheduling delays were exacerbated by the fact that community hospitals and physicians frequently were not paid accurately or quickly by PPS.

Herdman and his colleagues responded by introducing a “third-party administrator” system in which healthcare insurers contract with providers on behalf of PPS and process all provider claims.

“Third-party administrators have a track record of timely payments to providers,” he says, “and inmate access to outside healthcare improved dramatically.”

Prisoners now have access to a wide range of physicians, and the prison system has contracts with every hospital in the city. All doctors at PPS are board-certified, and 90 percent of the specialists seen by prisoners are university-faculty physicians. The prison healthcare system has 350 fulltime providers and 400 part-time providers—and it needs them, since Philadelphia, according to a 2010 analysis by the Pew Foundation, has the fifth-highest rate of incarceration in the country.

According to Herdman, 80 percent of PPS inmates are awaiting trial or sentencing. “It takes quite a while for cases, especially murder cases, to go to trial,” he says. “The average time-to-trial of a murder case in Philadelphia is about two-and-a-half years.”

That puts more pressure on the prison system and increases the city’s financial burden, he notes, but prisoners are guaranteed access to healthcare under the Constitution, and that level of access “has been held up in the courts.”

If inmates benefit from this care, taxpayers sometimes do, too. When Herdman took over in 2006, only 5 percent of inmates volunteered for AIDS testing. That number has risen to 95 percent, thanks to programs that he instituted encouraging inmates to be tested. When HIV-positive inmates are cared for and put on a drug regimen, their health improves, and when they leave prison and stay on their drug routine, the chances of them infecting someone else are greatly reduced. (While there is still a potential for infection by medication-compliant HIV-positive individuals, Herdman says that recent studies have shown that transmission rates are reduced by 98 percent.)

He’s particularly proud of the system’s conversion of prisoner medical records from paper files to an electronic database. As a result, he says, when a prisoner is moved from one prison facility to another—say from minimum security to medium security—doctors at the next facility can have immediate access to all records, thus assuring improved continuity of care.

Herdman hopes to launch a pilot program that would reduce the recidivism of those charged with prostitution.

“PPS houses about 100 women a day who have been charged with prostitution,” he says. “These folks are usually bailed out quickly but very often are rearrested, many multiple times. The program we are hoping to replicate reports that two-thirds of its graduates hold living-wage, legitimate jobs three years after release and are leading normal lives.”

Kristin Gavin, founder of Gearing Up (an organization that assists women in the PPS) calls Herdman “the great facilitator,” adding: “What he has done is to pay attention to small community-based programs that can bring about change in prisons. Without a doubt he’s made a difference in the lives of the prison population.”

While Herdman is proud of his work at his earlier positions, he makes one thing clear: “This is the most rewarding job I’ve ever had.”

—Jon Caroulis

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