Specialist physicians, generally working under contract to the Bureau of Prisons, periodically come into prisons to provide care to inmates. For this report, such contacts between a specialist and a patient are termed "internal specialist encounters"; the session during which a group of patients is seen by a specialist inside the prison is termed a "clinic."

Service utilization is characterized not by type of diagnosis but rather by the specialty of the consulting specialist. This is done for several reasons: The Bureau’s automated medical data system -- the Sensitive Medical Data (SMD) -- is not reliable at the diagnosis level; there were insufficient numbers of encounters in any diagnosis category to support analyses at this level; and the costs for internal specialty clinics vary by specialist rather than by the type of case he or she treats.

The Bureau’s SENTRY data system collects in- formation on many events in an inmate’s incarceration, including health care events. Every visit to a health professional, whether a Bureau employee, a consulting specialist, or a community hospital, is recorded. These paper records are then entered into a computerized database, which forms the SMD system. Although prisons do not enter data in exactly the same way, the contents of each SMD record generally include the following information:

• The date and time of the medical encounter.

• The type of clinician seen (physician, physician assistant, nurse practitioner, visiting specialist, external specialist).

• An International Classification of Diseases, 9th Revision (ICD-9) code classifying the medical condition involved.

Identifying the consulting physician’s specialty required some data analysis and inference because this information is not recorded in the SMD. By grouping ICD-9 codes, it is possible to infer the specialty of a consulting physician. Generally, if more than one ICD-9 code is indicated on the form, prison staff create separate records for each ICD-9 code rather than entering multiple ICD-9 codes in one record. For internal specialist encounters, the visiting specialist always sees more than one patient in a clinic. By grouping records chronologically and then by inmate identification number, the type of specialist consulting and the number of encounters (that is, the number of individual inmates seen) can be inferred. Medical records occasionally are needed for definitive inferences about the specialty of a visiting physician.

This report focuses on four specialties: psychiatry, orthopedics, dermatology, and cardiology. These specialties were selected for the following reasons:

• They can be identified in the SMD -- some clinical sessions (for example, dietary counseling) were not recorded prior to the telemedicine demonstration, and others (for example, podiatry) cannot be extracted from SMD as a defined specialty.

• Each of the four specialties is being provided under contract with a visiting specialist by one or more of the demonstration prisons.

• These four specialties are being offered using telemedicine, which might be expected to alter the patterns of internal encounters in these specialties.

Clinical staff employed at each prison also provide care, which can generally be categorized as primary care (although some facilities employ psychiatrists). Care provided by BOP employee clinicians was not analyzed for several reasons. First, SMD data are unreliable for clinician type; encounters with physician assistants cannot reliably be distinguished from encounters with physicians. Second, physician assistants run regular group sessions with inmates with chronic care problems -- for example, hypertension counseling with cardiac patients. These appear in the SMD as individual encounters and not as the group sessions they really are; therefore, individual encounters between employee clinicians and patients cannot reliably be counted. Finally, these visits with staff clinicians are for primary care and occasionally result in referrals to specialists, including remote specialists. The primary care encounters are a prelude to specialist care, not a substitute for it. (Primary care is not being offered telemedically.) For all of these reasons, the analysis omits analysis of care provided by Bureau-employed clinicians.

Internal Specialist Encounters: Costs

Data source: Specialist contracts and bills.

Physician fees. Each prison contracts with specialists who come into the prison to see inmates; the specialties vary among prisons but include psychiatry, orthopedics, dermatology, and cardiology. Care that requires a specialist physician not employed by the Bureau at that prison and that can be provided inside the prison is nearly always handled by these visiting specialists. Contracts are generally negotiated on a per-clinic basis, with broad guidelines about the duration of each clinic (for example, 2-4 hours per clinic). That is, the specialist is paid a flat fee for each prison visit. The negotiated fees charged by specialists at the studied prisons were obtained. For purposes of determining the physician-fee portion of each patient’s care, the flat, per-clinic rate a specialist has negotiated divided by the number of patients seen during each clinic was used.

Other. Other costs associated with internal specialist encounters are not as readily measured. These include pulling medical records and refiling them afterward and the costs of a physician assistant who accompanies the specialist during all encounters and follows through on all physician orders. The largest component of these costs is the physician assistant’s time. Physician assistant and administrative costs did not change between baseline and intervention periods and have essentially equivalent counterpart costs for telemedicine clinics when a physician assistant presents each case to the remote specialist.