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FINAL
REPORT

Health Care Services in State Correctional
Facilities – Weaknesses Exist in MDOC’s Monitoring
of Contractor Compliance and Performance; New
Administration is Undertaking Systemic Changes
Report No. SR-MEDSERV-09

Issues noted during this review:
• Medications Not Properly Administered and/or Recorded (pg. 10)
• Medical Files Not Complete or Consistently Maintained (pg. 11)
• Required Annual Health Exams Not Consistently Tracked and Sometimes Not Performed (pg. 12)
• Response to Sick Calls Not Timely and/or Inadequately Documented (pg. 12)
• Staff Training Insufficient and Poorly Documented (pg. 13)
• MDOC Systems for Monitoring Contractor Performance Inadequate (pg. 14)
• MDOC Contracts Not Structured to Help Contain Health Care Costs (pg. 14)

a report to the
Government Oversight Committee
from the
Office of Program Evaluation & Government Accountability
of the Maine State Legislature

November

2011

GOVERNMENT OVERSIGHT COMMITTEE OF THE 125TH LEGISLATURE
Senator Roger J. Katz, Chair
Senator Margaret M. Craven
Senator Bill Diamond
Senator Earle L. McCormick
Senator Nancy B. Sullivan
Senator A. David Trahan

Representative David C. Burns, Chair
Representative Andrea M. Boland
Representative Joyce A. Fitzpatrick
Representative Leslie T. Fossel
Representative Stephen D. Lovejoy
Representative Donald E. Pilon

OFFICE OF PROGRAM EVALUATION & GOVERNMENT ACCOUNTABILITY
Director Beth Ashcroft, CIA
Staff
Jennifer Henderson, Principal Analyst
Wendy Cherubini, Senior Analyst
Scott Farwell, Analyst
Matthew Kruk, Analyst
Maura Pillsbury, Analyst
Etta Connors, Administrative Secretary

Mailing Address:
82 State House Station
Augusta, Maine 04333-0082
Phone: (207) 287-1901
Fax: (207) 287-1906
Web: http://www.maine.gov/legis/opega/
Email: etta.connors@legislature.maine.gov

ABOUT OPEGA & THE GOVERNMENT OVERSIGHT COMMITTEE
The Office of Program Evaluation and Government Accountability (OPEGA) was created by statute in 2003 to
assist the Legislature in its oversight role by providing independent reviews of the agencies and programs of State
Government. The Office began operation in January 2005. Oversight is an essential function because legislators
need to know if current laws and appropriations are achieving intended results.
OPEGA is an independent staff unit overseen by the bipartisan joint legislative Government Oversight
Committee (GOC). OPEGA’s reviews are performed at the direction of the GOC. Independence, sufficient
resources and the authorities granted to OPEGA and the GOC by the enacting statute are critical to OPEGA’s
ability to fully evaluate the efficiency and effectiveness of Maine government.
Requests for OPEGA reviews are considered by the Governor Oversight Committee in accordance with a
standard process. Requests must be made in writing and must be initiated or sponsored by a legislator.
Individual legislators or citizens should review the process and FAQ that are posted on OPEGA’s website at
http://www.maine.gov/legis/opega/ProcessProducts.html. There is also a form there to help facilitate the
GOC’s consideration of the request. Legislative committees can request reviews directly through a written
communication to the Government Oversight Committee.
Copies of OPEGA’s reports are free.
Reports are available in electronic format at:
http://www.maine.gov/legis/opega/
Hard copies of reports may be obtained by contacting OPEGA at:

(207) 287-1901
Office of Program Evaluation & Government Accountability

82 State House Station • Augusta, ME • 04333-0082

Health Care Services in State Correctional Facilities

Table of Contents―――――――――――――――――――――――――――――
Introduction
Questions, Answers and Issues
In Summary
Standards for Correctional Health Care
Challenges in Correctional Health Care Administration
National Standards for Correctional Health Care
Incorporating Standards into the Health Delivery System
MDOC’s Delivery of Health Care Services
General Background
MDOC’s Current Contract for Health Care Services
MDOC’s Current Contract for Pharmaceutical Services
Issues Noted by OPEGA’s Correctional Health Care Consultant
Medications Not Properly Administered and/or Recorded
Medical Files Not Complete or Consistently Maintained
Required Annual Health Exams Not Consistently Tracked and Sometimes Not Performed
Response to Sick Calls Not Timely and/or Inadequately Documented
Staff Training Insufficient and Poorly Documented
MDOC Systems for Monitoring Contractor Performance Inadequate
Contracts Not Structured to Help Contain Health Care Costs
Recent Changes in MDOC’s Health Care Administration
Changes in MDOC’s Organizational Structure
Changes in Philosophy on Services Provided
Recommendations
Agency Response
Acknowledgements
Appendix A. Scope and Methods
Appendix B. OPEGA Information Brief – Heath Care Services in State Correctional Facilities: Opportunities
to Contain Costs and Achieve Efficiencies

1
2
3
4
4
5
5
6
6
8
9
10
10
11
12
12
13
14
14
15
15
17
18
23
25
26

Health Care Services in State Correctional Facilities

Health Care Services in State Correctional Facilities

Health Care Services in State Correctional Facilities – Weaknesses Exist in
MDOC’s Monitoring of Contractor Compliance and Performance; New
Administration is Undertaking Systemic Changes

Introduction ―――――――――――――――――――――――――――――――――
The Maine Legislature’s Office of Program Evaluation and Government
Accountability (OPEGA) has completed a review of Health Care Services in State
Correctional Facilities. This review was performed at the direction of the
Government Oversight Committee for the 124th Legislature. OPEGA contracted
with an expert consultant, MGT of America, Inc. (MGT), to conduct most of the
fieldwork for this review.
This review was focused
on health care services
delivered by MDOC’s
primary contractors, CMS
and CorrectRX. OPEGA
contracted with an expert
consultant, MGT, to
conduct the fieldwork.

MDOC’s administration of
prisoner health care
services has been in a
state of continuous
change over the course of
this review. This report
reflects issues drawn from
audit work conducted in
fall 2010, relevant actions
taken by the new
administration, and
recommendations for ongoing improvements.

The review’s scope was limited to the adult and juvenile correctional facilities
operated by the Maine Department of Corrections (MDOC). It was also specifically
focused on the health care services delivered to prisoners by the private
correctional care providers Correctional Medical Services (CMS) 1 and CorrectRx.
Contracts with these providers represent most of the health care dollars spent on
State prisoners, all of which are supported by the State’s General Fund.
MGT conducted its fieldwork from September through November 2010 and began
sharing its preliminary issues and recommendations with OPEGA and MDOC in
January 2011. Subsequently, OPEGA discussed issues raised by MGT with MDOC
management and performed some additional document review in the course of
finalizing the issues and recommendations for this report. See Appendix A for
complete scope and methods.
MDOC’s administration of health services for prisoners has been in a state of
continuous change since OPEGA began this review in the summer of 2010 and
continues to undergo changes as this report is being published. When the review
was initiated, the MDOC position of Health Care Services Director was vacant.
The position is responsible for administration and oversight of health care services
and was filled just prior to MGT beginning the fieldwork. In January 2011, while
OPEGA was just beginning discussions with MDOC about reportable issues and
corrective actions, a new Governor assumed office. A new MDOC Commissioner
was appointed and started in the position in late February and the staff in other
administrative positions directly related to managing health care services began to
change as well.
As a result, OPEGA put this project on hold during the spring of 2011 to allow
time for the new management of MDOC to familiarize themselves with the
Department’s functions, review the MGT findings, and form their own conclusions
about the state of health care services in MDOC facilities. This report now reflects
issues drawn from MGT’s point in time look at the Department’s health care
services for prisoners during the fall of 2010, the relevant actions that have been
taken to date by the new administration, and OPEGA’s recommendations for
ongoing improvements.
Correctional Medical Services has recently undergone organizational changes and now is
know as Corizon.
1

Office of Program Evaluation & Government Accountability

page 1

Health Care Services in State Correctional Facilities

Questions, Answers and Issues ―――――――――――――――――――――
1. How well does the Maine Department of Corrections (MDOC) manage its contracts for medical, dental,
pharmaceutical, and adult mental health services to ensure compliance with contract terms, conditions
and expectations with regard to performance, quality and cost?
see page 6 for
more on this point

The burden of delivering quality health care services to prisoners in a manner
consistent with professional standards is the responsibility of the vendors that the
State contracts to provide these services. MDOC sets the standards of care to be
met by the contractors, both through contract language and through the policies
and procedures established for health care delivery. OPEGA’s correctional health
care consultant, MGT, found the terms of the contracts in effect in fall 2010 did
adequately address the most critical areas of prisoner health care services.
However, ensuring contractors meet the standards set by the Department requires
effective contract monitoring systems as well as strong systems for developing and
communicating policy. MDOC’s efforts in this area were not always adequate to
ensure that expected standards of care were met. The weakness in monitoring
appears to be due to the close and cooperative relationship that has existed
between MDOC and its contractors, particularly its primary health care vendor,
CMS. This type of partnership has advantages, but also carries significant risk when
it interferes with the arms-length monitoring needed to ensure accountability and
protect service quality.

2. How well are the selected contractors complying with the contract terms and provisions, relevant
regulations and accepted practices that are most critical in delivering health care services to prisoners?

see page 10 for
more on this point

Most of MDOC’s facilities have been accredited by the American Correctional
Association (ACA) which, in terms of health care, means that service levels meet
the basic performance standards established in the profession. Nonetheless, MGT
found that CMS did not always comply with contract provisions requiring
adherence to MDOC policies – even in the accredited facilities. Adherence to
professional standards for medical care was also lacking in some areas. MGT
observed that some prisoners did not receive standard medical services, such as
physicals, dental services or sick call response within the timeframe required by
MDOC’s contracts. Persistent issues with proper administration of prescribed
medications were also noted.
A new administration is now managing the Maine Department of Corrections and
a Request For Proposal will soon be issued soliciting bids for the provision of all
correctional health care services in State facilities. This is an opportune time to
establish better mechanisms for monitoring contractors and holding them
accountable for compliance with their contract provisions. Such efforts will help
ensure prisoners receive appropriate and timely health care services.

Office of Program Evaluation & Government Accountability

page 2

Health Care Services in State Correctional Facilities

The following issues were identified during the course of this review. See pages 18 - 22 for further discussion
and OPEGA’s recommendations.
•
•
•
•
•
•
•

Medications Not Properly Administered and/or Recorded
Medical Files Not Complete or Consistently Maintained
Required Annual Health Exams Not Consistently Tracked and Sometimes Not Performed
Response to Sick Calls Not Timely and/or Inadequately Documented
Staff Training Insufficient and Poorly Documented
MDOC Systems for Monitoring Contractor Performance Inadequate
MDOC Contracts Not Structured to Help Contain Health Care Costs

In Summary―――――――――――――――――――――――――――――――――――――
MDOC and its health
services contractors
generally provide
adequate prisoner care.
However, some
deficiencies in contractor
compliance with MDOC
policies and adherence to
professional standards
were noted.

MDOC has not had a
strong system for
monitoring contractor
performance and has not
held contractors
accountable for resolving
issues identified. The longterm, cooperative
relationship between
MDOC and its contractors
appears to be a
contributing factor.

MDOC has contracted with its major health care services provider, CMS, for nine
years and with its pharmacy provider, CorrectRX, for five years. The terms and
conditions of those contracts, including requirements to adhere to MDOC policies
and procedures, are key mechanisms for ensuring adequate care for prisoners.
While MDOC and its contractors generally provide more than adequate care to the
prisoner population, deficiencies in contractor compliance with MDOC health care
policies and adherence to professional standards were noted. Some of these
deficiencies appeared to be persistent, with clear implications for the adequacy and
timeliness of services provided to prisoners. Examples include issues related to
medication administration and response to prisoner sick calls.
MDOC has not had a strong and effective system for monitoring contractor
performance and compliance, or held the contractor sufficiently accountable for
resolving issues when they were identified. The long-term relationship between
MDOC and its contractors appears to be a contributing factor as the delivery of
health care has become more of a partnership than an arms-length arrangement.
The facilities appear to be staffed with committed health care professionals and a
good working relationship exists between MDOC and CMS, particularly at the
clinical level. However, this working relationship needs to be tempered with an
appropriate commitment to critical assessment of vendor performance, holding the
vendor accountable, and improving the cost-effectiveness of the current
contractual relationship.
MDOC had begun planning a new RFP for health care services when fieldwork on
this review commenced in the fall of 2010. OPEGA’s consultant, MGT, suggested
approaches to be used in the RFP and the eventual design of the contractual
relationship to help reduce correctional health care costs and maintain or improve
quality. MGT shared these suggestions with MDOC, and OPEGA reported on
these opportunities to the Legislature in an Information Brief earlier this year. (See
Appendix B).
During the course of OPEGA discussions with MDOC on the performance issues
identified by MGT, there was a transition to a new administration. The new
MDOC administration subsequently began taking significant actions impacting the
Department’s relationship with its contractors and the health care services

Office of Program Evaluation & Government Accountability

page 3

An RFP for health care
services will soon be
issued and MDOC’s new
administration seems to
be taking positive steps
toward improvements in
the quality and cost of
prisoner health care.

Health Care Services in State Correctional Facilities

delivered to prisoners. The completed and planned actions, as described to
OPEGA, are positive steps and the Department currently appears to have
substantial momentum directed toward change and improvement. As expressed in
our recommendations, OPEGA considers continuation of those efforts critical to
addressing the root causes of issues identified by OPEGA’s consultant MGT.

Standards for Correctional Health Care ――――――――――――――――――
Challenges in Correctional Health Care Administration

Prisoners have legal rights
to receive adequate and
timely care. The prisoner
population tends to have
special issues that make
delivery of health services
in a correctional setting
more challenging than in a
community setting.

Understanding how correctional health care administration has evolved in the
United States provides necessary context for evaluating how health care services are
managed by MDOC. The legal rights of prisoners in the United States to receive
adequate and timely medical treatment are well established. In 1976, the U.S.
Supreme Court in Estelle v. Gamble established that health care for prisoners is a
right embodied in the eighth amendment of the U.S. Constitution, affirming that
prisoners have a right to be free of deliberate indifference to their health care
needs. Since the mid-70’s corrections agencies have implemented policies and
procedures to meet this legal requirement.
Issues with the delivery of health services in a correctional setting differ somewhat
from those of the community. Assuring adequate health care to prisoners requires
ongoing attention to a number of special issues, including the following:
•

Many prisoners have little or no history of good preventive medical or
dental care.

•

High-risk lifestyles lead to the early on-set of medical conditions, often
rising to the level of chronic care needs (medical care which addresses
preexisting or long term illness, as opposed to acute care which is
concerned with short term or severe illness of brief duration).

•

A large portion of the prisoner population suffers from serious diseases.

•

Many prisoners express dissatisfaction in types of medications being
prescribed and often seek narcotic-level pain medications because of their
history with substance abuse.

•

Many prisoners are reluctant to cooperate in their own health care
treatment plans.

•

Prisoners often have a history of self-mutilating behavior, aggression and
violence toward others, lack of education, need for power and control, poor
work history, and other anti-social characteristics.

•

The social disposition of some prisoners creates reluctance to have trust in
medical caregivers.

•

Prisoners can benefit from patient education, but are often not likely to
comply with the direction provided.

•

Establishing a continuum of patient care to follow prisoners upon their
release is challenging.

Office of Program Evaluation & Government Accountability

page 4

Health Care Services in State Correctional Facilities

National Standards for Correctional Health Care

Policies and standards
established by ACA and
NCCHC provide national
benchmarks and guidance
for the practice of
correctional health care.

The level of care available
to prisoners should
generally mirror what is
available to citizens in
their local community.

The challenge of delivering adequate health care to prisoners in compliance with
legal requirements has led to the development of comprehensive standards and
policies to assist correctional administrators. Organizations such as the American
Correctional Association (ACA), the National Commission on Correctional Health
Care (NCCHC), the American Medical Association (AMA), and the American
Public Health Association (APHA) all have made substantial contributions to the
development of these standards. As a result of these efforts, the basic principles of
correctional health care management are well-established and are a significant
component of most state and local correctional systems.
Policies and standards established by the ACA and the NCCHC provide national
benchmarks for the effective operation of correctional health care throughout the
United States. These standards address clinical issues, treatment protocols,
administrative controls, staff training and development, disease prevention, quality
assurance, safety and emergency procedures, data management, sanitation, and
other key issues, reflecting the professional consensus on best practices in all of
these areas. Throughout this report, references to best practices and current care
standards relate to the specific standards established by ACA and NCCHC to guide
the actual practice of correctional health care.
The basic guideline for the level of services provided has been, “the community
standard of care,” meaning that the level of care available to prisoners in the prison
system should generally mirror the level of service available to citizens in their local
community. Providing the range of comprehensive medical services available in the
community to prisoners in a correctional setting can be challenging. However, it is
the State’s responsibility to ensure prisoners have appropriate access to care,
consistent with the best use of available resources.
Incorporating Standards into the Health Care Delivery System

Health care performance
standards are established
in each correctional
system through agencyspecific policies and
specific provisions in
contracts with helath care
providers. ACA has an
accreditation system that
verifies compliance with
the national ACA
standards.

One outcome of the significant effort to improve correctional health care
management over the last thirty years has been substantially increased expenditures
for these services, particularly as the prisoner population has grown. In order to
better control these costs and gain access to expertise, many state and local
correctional systems have privatized correctional health care service delivery by
contracting with vendors and non-correctional agencies that specialize in delivering
correctional health care services. There are a number of different approaches to
privatization, but many systems have adopted a model where the vendor or outside
agency provides on-site health care staff in the prison system, and supervises access
to and delivery of services both on-site, and, where necessary, off-site in the
community. MDOC has adopted this approach.
Correctional systems establish performance standards for both vendors and overall
system performance through the use of agency-specific health care policies that
reflect desired levels of performance, combined with effective contract monitoring.
The ACA maintains an accreditation system that verifies correctional agencies’ and
facilities’ compliance with the national standards promulgated by the ACA.
Accreditation is achieved through a series of reviews, evaluations, audits and
hearings.

Office of Program Evaluation & Government Accountability

page 5

Health Care Services in State Correctional Facilities

MDOC’s Delivery of Health Care Services ―――――――――――――――
General Background
Health care services are
provided at each of
MDOC’s facilities, mostly
through contracts with
third party providers.

The Maine Department of Corrections (MDOC) operates seven adult and two
juvenile penal institutions that housed more than 2,300 prisoners as of December
2010. MDOC is required to provide medically necessary health care to these
prisoners. MDOC provides medical, dental, pharmaceutical, substance abuse, and
mental health services, including psychiatry and mental health counseling, in both
its adult and juvenile facilities. Each facility offers some health care services. When
a facility is not able to provide the level of care a prisoner requires, the prisoner
may be transported to another correctional facility or off-site health care facility to
receive the necessary care.

Table 1. Summary of Health Care Services, Providers and Population by Correctional Facility- 2010
ADULT FACILITIES

AVG. POP.
2010

DENTAL

CMS

CMS

Psychiatry - CMS

CorrectRx

53

CMS

CMS

Psychiatry - CMS
M.H. Counseling - CMS

CorrectRx

136

CMS /
MDOC

CMS

Psychiatry - CMS
M.H. Counseling - CMS

CorrectRx

147

Maine Correctional Center

CMS

CMS

Psychiatry - CMS
M.H. Counseling - CMS and MDOC

CorrectRx

716

Maine State Prison and
Bolduc Correctional Facility

CMS /
MDOC

CMS

Psychiatry - CMS
M.H. Counseling - CMS and MDOC

CorrectRx

987

CMS

CMS

Psychiatry - CMS
M.H. Counseling - CMS

CorrectRx

28

MEDICAL

DENTAL

Long Creek Youth
Development Center

CMS/
MDOC

CMS

Mountain View Youth
Development Center

CMS

CMS

Central Maine Pre-Release
Center
Charleston Correctional
Facility
Downeast Correctional
Facility

Women's Reentry Center
JUVENILE FACILITIES

MENTAL HEALTH

PHARMACY
SERVICES

MEDICAL

MENTAL HEALTH
Psychiatry - Stroudwater Assoc.
M.H. Counseling - Youth Alternatives,
Ingraham, MDOC, DHHS
Psychiatry - Acadia Hospital
M.H. Counseling - The Charlotte White
Center, MDOC, DHHS

PHARMACY
SERVICES

AVG. POP.
2010

CorrectRx

114

CorrectRx

81

CMS = Correctional Medical Services; MDOC = Department of Corrections; DHHS = Department of Health and Human Services
Source: Information provided by the Maine Department of Corrections.

Although a few State employees still participate in the delivery of health care
services, most services are provided through contracts with third parties as shown
in Table 1. Since 2003, MDOC has contracted with Correctional Medical Services
(CMS) to deliver medical, dental, and mental health care services and to administer
its health care program. Since 2007, MDOC has also contracted with CorrectRx to
provide pharmaceutical services in support of its health care program. MDOC is
poised to issue a new Request for Proposals (RFP) for all health services provided
in the correctional facilities, and intends to enter into new contracts for these
services in the first half of 2012.

Office of Program Evaluation & Government Accountability

page 6

Health Care Services in State Correctional Facilities

At the time of this review, both the CMS and the CorrectRx contracts were
managed by the MDOC Health Care Services Director and a new person had just
been hired into this position. The Department used a variety of methods to
monitor the quality of health care and pharmacy services provided by these
vendors, including management meetings, monthly reports, and periodic MDOC
and CMS audits. MDOC held yearly meetings with CMS to define expectations, bimonthly management meetings to discuss system-wide issues, monthly Medical
Audit Committee (MAC) meetings at Maine State Prison (MSP) and Maine
Correctional Center (MCC), and quarterly MAC meetings at the other MDOC
facilities. Figure 1 displays the MDOC’s management structure over the delivery of
health care services in its facilities as of December 2010.
Figure 1. Maine Department of Corrections Organizational Chart for Delivery of Health Care Services as of December 2010

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page 7

Health Care Services in State Correctional Facilities

MDOC’s health care
policies and operating
procedures follow ACA
standards. All but two
MDOC facilities have
qualified for full ACA
accreditation. Though
physical plant issues
prevent MDOC from
seeking accreditation for
those two facilities, the
Department is confident
that ACA medical
standards are being met
there as well.

MDOC’s health care policies
Acronyms for MDOC Facilities
and operating procedures
BCF - Bolduc Correctional Facility
generally follow ACA
CMPRC - Central Maine Pre-Release Center
standards. Both of MDOC’s
CFF - Charleston Correctional Facility
juvenile facilities (MVYDC
DCF - Downeast Correctional Facility
and LCYDC) and four of the
MCC - Maine Correctional Center
MSP - Maine State Prison
adult facilities (MSP, BCF,
WREC - Women's Reentry Center
MCC and CCF) currently
LCYDC - Long Creek Youth Development Center
have ACA accreditation.
MVYDC - Mountain View Youth Development Center
MCC just passed its
reaccreditation audit and the other five facilities are up for reaccreditation in 2012.
The Women’s Re-entry Center underwent its first ACA accreditation audit this
year, and MDOC recently learned that it will be recommended for accreditation.
MDOC has not sought ACA accreditation for the remaining two adult facilities CMPRC and DCF – as they would not meet ACA’s physical plant standards.
MDOC reports, however, that the medical departments at both those facilities are
held to the same ACA health care standards as the accredited facilities and there are
no differences in the policies and procedures or way care is delivered in the nonaccredited facilities. MDOC is confident that all ACA medical standards are being
met at CMPRC and DCF.
MDOC’s Current Contract for Health Care Services

MDOC’s contract with CMS
has been amended and
renewed multiple times
since it was awarded in
2003. The FY2012
amount for the contract is
just over $12 million.

The contract requires CMS
to provide certain services,
and manage overall health
care delivery for MDOC, in
a manner that complies
with MDOC policies and
medical care standards.
Achievement of ACA
accreditation is also a
contract requirement.

For FY 2012 the Department of Corrections’ contract with CMS totaled just over
$12 million and was entirely supported by the General Fund. The CMS contract,
originally awarded via a RFP process, has been amended 14 times and renewed
seven times since 2003. These amendments were related to increases in psychiatric
services, population growth, addition of a facility, revised staffing plans, reduction
in MaineCare reimbursement rates, and other factors.
Critical provisions of the CMS contract include requirements for:
• routine medical care;
• health examinations upon admission to the prison system;
• physical health assessments;
• physician, dental and optometry services;
• provision of medications and immunizations as prescribed;
• emergency medical response; and
• specialty and ancillary services.
The contract requires CMS to manage health care delivery for MDOC, including
negotiating payment rates, administering statewide health care programs,
maintaining appropriate staff licensure, providing training, conducting discharge
planning, administering medical records and providing overall clinical oversight. In
addition, CMS is required to comply with applicable MDOC regulations, policies
and medical care standards. Achievement of ACA accreditation is also a
requirement in the CMS contract.

Office of Program Evaluation & Government Accountability

page 8

Health Care Services in State Correctional Facilities

CMS’s contract also specifies the number and type of staff the contractor is
required to provide at each facility. These contracted staff totaled 98 full time
equivalents (FTEs) as of December 2010, but CMS was having persistent
difficulties recruiting and retaining staff in some positions. Although the contract is
for a specified dollar amount, CMS’s final compensation is determined by the cost
of actual staff and services provided, plus administrative costs.
MDOC’s Current Contract for Pharmaceutical Services

CorrectRX has been
contracted to provide
pharmaceutical services
since 2006. Those
services are to be provided
in accordance with State
and federal standards as
well as those of the
NCCHC and ACA.

CorrectRX is also required
to provide regular
utilization and monitoring
reports and to visit each
facility every three months
to check that medications
are being properly
administered.

The CorrectRx contract for pharmaceutical services at MDOC facilities was
originally awarded via RFP in December, 2006 and has been amended and/or
renewed four times since then. The current agreement is for $3,258,000 and can be
adjusted up or down if costs exceed or are less than this amount. Under this
contract, CorrectRx provides the following services in accordance with State and
federal standards as well as those of the National Commission on Correctional
Health Care (NCCHC) and American Correctional Association (ACA):
• performs all monitoring services expected of a pharmacy including
quarterly inspection of medication rooms and carts at all MDOC facilities
where needed;
• makes available a licensed pharmacist by telephone for consultation;
• delivers all prescriptions and non-prescription medications to each facility
in a timely manner; and
• works cooperatively with all MDOC facility staff and medical and
psychiatric services contractors and subcontractors to ensure timely and
appropriate delivery of medications and health care services to all prisoners
and residents.
CorrectRx also maintains arrangements with community pharmacies located in
close proximity to correctional facilities for an emergency backup supply of
medications.
The contract with MDOC requires CorrectRx to provide a number of regular
reports to State administrators. These reports include quarterly utilization data,
pharmacy services and facility monitoring reports, and quality assurance reports. In
addition, CorrectRx must ensure a registered pharmacist visits each MDOC facility
at least every three months to perform the following tasks:
• review medication administration records for appropriateness of
documentation;
• review drugs on site for dating and storage;
• ensure that medications are being destroyed appropriately;
• provide recommendations as to therapy; and
• provide education as needed.

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Issues Noted by OPEGA’s Correctional Health Care Consultant ――
OPEGA’s consultant, MGT,
identified numerous
compliance issues, some
of which were challenged
by the MDOC health care
administrators in place in
January 2011.

OPEGA was still in
discussions with MDOC
over these issues when
MDOC health care
administration began to
change. The new
administrators are now
incorporating actions on
all issues MGT identified
into larger, systemic
changes they are pursuing.

The work performed by OPEGA’s consultant, MGT, is described in Appendix A.
It included review of the relevant health care services contracts and Departmentwide policies and procedures, as well as interviews and observations at each of the
facilities operated by MDOC. In addition, MGT conducted more in-depth review
at the two largest adult facilities – Maine Correctional Center (MCC), and Maine
State Prison (MSP) – and Long Creek Youth Development Center (LCYDC) which
houses the most juveniles 2 . MGT reviewed the facility-specific policies and
procedures, prisoner grievance logs, minutes of Medical Audit Committee meetings
and other site specific materials at each of the three locations. A sample of 24
prisoner medical files, spread across the three facilities, was also examined to
determine compliance with key MDOC health care policies, contract provisions
and correctional health care standards. MGT’s sample was judgmentally selected
from a list of current prisoners at each facility provided by MDOC.
The draft findings and recommendations resulting from MGT’s work generated
considerable discussion between OPEGA and the MDOC health care
administrators in place in January 2011. MDOC agreed with some of the issues
identified and explained challenges they faced that had contributed to those issues.
On other issues, however, they challenged whether the exceptions were significant
enough to warrant requiring CMS to take corrective action. For example, they felt
the sample of medical files MGT reviewed was not large enough to be
representative of overall conditions. They planned to conduct their own file review,
with a much larger sample, to determine whether the concerns were valid. They
also felt some exceptions identified by MGT were isolated incidents or had
explanations that negated them.
While OPEGA was still in discussions with MDOC, a new commissioner was
appointed to the Department who began making changes to staff in other
administrative positions directly related to managing health care services. OPEGA
subsequently discussed MGT’s results, described below, with MDOC’s new
administration. The new administrators are incorporating actions to address these
issues into larger, systemic changes they are pursuing in correctional health care.
Medications Not Properly Administered and/or Recorded

MGT noted exceptions in
documentation of
medications dispensed for
59% of the prisoner
medical files reviewed.

MGT reviewed medication administration registers for the month of September
2010 for the sample of 24 prisoners, only 22 of whom were on medication. The
results are summarized in Table 2. MGT found that CMS did not maintain files to
show prisoners received medications as prescribed in more than half of the cases
reviewed. For 11 of the 22 prisoners (50%), there was no evidence in the file that
medications were dispensed per doctor’s orders. These prisoners had no entries in
the time slots on the medical administration register to indicate whether the

Maine State Prison and Maine Correctional Center together house about 78% of the total
adult prisoners in the State correctional system. Long Creek Youth Development Center
houses about 58% of the total juveniles in the system.

2

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prisoner took his medication, refused his medication, was absent at the pill line, or
received the medication. For 2 prisoners (9%), medication administration registers
could not be provided by medical staff.
Table 2: Results from Testing of Medication Administration Registers at Three MDOC Facilities
Files with No
Total Number of
Number of
Files with No Evidence
Medication
Prisoners Files
Prisoners on
Medication was Properly
Administration
Institution
Tested
Medication
Dispensed
Percent
Registers
Percent
MCC*
14
12
6
50%
1
5%
MSP
7
7
4
57%
0
0%
LCYDC
3
3
1
33%
1
33%
Total
24
22
11
50%
2
9%
*MCC has sections for both male and female prisoners. The sample included files for 11 male and 3 female prisoners.
Source: MDOC medical files, as reviewed by MGT of America Inc.

Minutes of 2010 meetings
between CMS and MDOC,
and prisoner grievances,
indicate on-going issues
with medication
administration that should
have resulted in corrective
action.

Minutes of management meetings between CMS and MDOC reflected ongoing
concerns during 2010 regarding incorrect medications being given to prisoners,
inconsistency with following stop and start dates of prescriptions and other poor
practices associated with medication tracking and labeling. Meeting notes indicated
that new procedures, better staff training and staff counseling were considered as
potential solutions, but did not indicate whether any actions were taken. Several
prisoner grievances or complaints related to medication were also filed during fiscal
year 2009-10. The issues grieved included medication being distributed late,
incorrect dosages, and incorrect medications given.
Failing to provide the correct medication within the prescribed time frame is a
violation of MDOC policies and accepted best practices. Professional standards call
for the correct medication to be delivered to each prisoner in the prescribed
amount and at the correct interval as prescribed by the physician. All dispensation
of medications should be documented, including refusals to take medication as
ordered.
Medical Files Not Complete or Consistently Maintained

MGT found that 46% of
files reviewed did not have
all required intake forms
completed. Thirty-three
percent also had sign-in
sheets that were missing
or not properly used.

MGT found that CMS staff did not consistently follow MDOC policies related to
medical intake and medical records. Specifically, CMS staff did not always ensure
required intake forms and the required intake checklist were completed and
included in prisoners’ files. Of the 24 medical files reviewed, 15 (63%) did not have
completed intake checklists and 11 (46%) did not have all the required intake forms
completed.
Policy also requires that medical files contain an accurate and updated sign-in sheet
with clear signatures and initials of employees and practitioners who update the file.
The intent is to be able to identify the individuals whose signatures or initials are
written in the medical chart. Three of the 24 files reviewed did not include a sign-in
sheet at all and another five included a sign-in sheet that was blank or not updated.
In some cases, the medical personnel writing to the chart had not signed the log.
MGT also noted inconsistent understanding among staff at the facilities as to what
the sign-in sheet was for and who should be signing it.

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Required Annual Health Exams Not Consistently Tracked and Sometimes
Not Performed
Thirty-eight percent of files
reviewed had inaccurate
records for physical exams
and 13% did not have any
dental intake records at
all.

MGT found that CMS staff did not always properly document prisoner physical
assessments and did not always provide annual physical assessments as required by
the MDOC contract. The means of tracking when annual physical assessments
were due was inconsistent and manual across facilities, despite the fact that all
facilities were managed by CMS. As shown in Table 3, nine of the 24 medical files
(38%) MGT reviewed had inaccurate records regarding physical assessments. Three
prisoners—one of whom also had inaccurate records regarding physical
assessments—had not received all required annual physical assessments.

Table 3: Results from Testing of Required Annual Physical Exams at Three MDOC Facilities
Total Number Prisoners with Inaccurate
Prisoners Who Did Not
of Prisoners
Files Regarding Physical
Receive All Annual
Institution
Files Tested
Assessments
Percent
Physical Assessments
MCC*
14
2
14%
1
MSP
7
6
85%
2
LCYDC
3
1
33%
0
Total
24
9
38%
3

Percent
7%
29%
0%
13%

*MCC has sections for both male and female prisoners. The sample included files for 11 male and 3
female prisoners.
Source: MDOC medical files, as reviewed by MGT of America Inc.

Three of 24 prisoners had
not received annual
physical exams and two
had not received annual
dental services.

CMS medical staff also failed to ensure dental intake and annual dental assessments
were completed, or that documentation of them was included in prisoners’ medical
files. Exceptions were noted in five of the 24 (21%) prisoner medical files reviewed.
Three of those files (13%) did not have any dental records (and this was not due to
the prisoner having been newly incarcerated), and two others (8%) had records
indicating the prisoner had not received the annual dental services that appear to be
required by MDOC policy.
Response to Sick Calls Not Timely and/or Inadequately Documented

MGT noted exceptions with
response time or
documentation for 11% of
the 203 sick call slips
reviewed.

“Sick call” is a critical service provided to prisoners and guaranteed by CRIPA—
the Civil Rights of Institutionalized Persons Act. Sick call slips allow a prisoner to
alert health care staff of the desire or need for non-emergency medical or dental
services. MDOC policy provides for sick call slips to be “readily available” to all
prisoners, with medical staff at each facility establishing their own systems to
process the sick call slips. Policy further states that “all non-emergency sick call
slips shall be reviewed by nursing staff within 24 hours of receipt” and the prisoner
shall be “seen by qualified health care staff within the next 24 hours (72 hours on
weekends)”.
MGT reviewed 203 sick call slips for the 24 prisoners whose medical files were
reviewed. MGT found 23 slips, or 11%, that were either not resolved timely or had
no resolution date or actions noted in the medical file. MDOC health care
management meeting minutes in 2010 indicated the sick call process was too timeconsuming and there were too many sick calls to process in the time allotted for
that purpose. MGT noted that this problem was hard for MDOC to quantify
because sick call slips are kept in prisoners’ individual files. As a result, there is no
easily aggregated data to help understand the amount of time being spent by staff
on sick calls, the number of sick call slips being submitted by prisoners, or whether

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Minutes of 2010 meetings
between CMS and MDOC
show concerns about the
sick call process and
inabilities to handle the
high number of sick calls
within the time allotted for
them.

Changes to the sick call
process have now been
made to address
documentation and other
issues.

specific prisoners are particularly high users of sick call services and could perhaps
have their health needs more efficiently met through some other avenue.
According to MDOC and CMS staff, during October 2010, a new sick call process
was being developed cooperatively between MDOC and CMS to address these
issues and provide better care. The new administration has followed through on
that effort and also implemented additional improvements.
Facility nurses are now required to log the date and time when they examine a
prisoner’s sick call slip, as well as the response they determined was appropriate. In
the past, prisoners complained days had gone by since they submitted a sick call
with no attention to their medical concerns. Nurses claimed the prisoners had been
seen within a few hours of their requests and it was determined no further medical
attention was required. There should now be a record of nurses’ actions, so
although prisoners may still dispute whether the actions were appropriate, there can
be no question as to whether the sick call was responded to within the timeframes
required by MDOC policy.
MDOC also reports having made changes to how the security and medical teams
work together to handle sick calls. In September 2011, MDOC reported to
OPEGA that the Health Services Coordinator had recently completed an audit of
files to ensure CMS was following the new procedures and improving compliance
with sick call standards.
Staff Training Insufficient and Poorly Documented

MGT noted that:
•

health care staff were
not sufficiently
knowledgeable of
MDOC policies and
health care standards;

•

CMS was having
difficulty fulfilling some
training requirements;
and

•

training received by
staff at MSP was not
well documented.

CMS’s contract specifically designates the vendor as responsible for providing
training programs for all health care staff, whether MDOC or CMS personnel, as
well as training for other security and non-security staff as outlined in an annual
training plan. This training should cover topics associated with ACA accreditation,
since achievement of accreditation is required under the contract and contingent
upon staff adhering to ACA guiding principles, rules, and standards. However,
MGT noted several conditions indicating that training of MDOC and CMS staff
was insufficient. In addition to the failures to maintain proper medical records
already discussed, MGT also reported that:
•

Discussions with medical staff during the fall of 2010 revealed that MDOC
and CMS medical staff were not familiar with the full range of correctional
health care standards that apply to the system. MGT also noted mixed
understanding of MDOC’s agency-wide and facility-specific operating
policies.

•

Minutes of health care management meetings in 2010 recorded staff
concerns regarding insufficient training for CMS staff. The minutes also
recorded that CMS was having an issue with providing required First Aid
and CPR training to all MDOC staff due to the volume of staff to be
trained.

MGT requested the training files for staff members from each of the three facilities
selected for detailed review—MCC, MSP, and LCYDC. The training files were
difficult to obtain at MSP, and when found, were poorly organized and difficult to
follow, making it a challenge to ascertain whether required trainings had been

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delivered. As of December 2010, MDOC acknowledged issues in delivery and
documentation of training, but believed all required training was being provided.
MDOC Systems for Monitoring Contractor Performance Inadequate
MDOC has permitted CMS
to monitor and report on
its own performance
rather than establishing
independent systems to
ensure CMS meets
contract requirements,
provides adequate care,
and manages costs
reasonably.

Minutes of meetings
between CMS and MDOC
also show identified issues
being on the agenda
month after month in
2010 with no actions or
resolution recorded.

Although MDOC policy requires an internal system of review, as of fall 2010 the
Department was permitting CMS to monitor and report on its own performance.
The Department had very little in the way of independent systems to oversee the
contractor and ensure CMS was delivering on the contract requirements, providing
adequate care to prisoners, and managing costs reasonably. MGT noted it appeared
that MDOC and CMS had worked together for so long that their relationship had
taken on the tone of a partnership between equals and lost the “arms-length”
nature of most contractor-customer relationships. This is exemplified in MDOC’s
hesitancy to hold CMS accountable when contract requirements were not fulfilled.
In a follow-up discussion regarding this matter in December 2010, MDOC’s
Health Care Services Director agreed that better performance management was
needed, and stated that actions were already underway to improve in this area.
However, she cited the lack of readily available performance and outcome data as
complicating efforts to assess contractor performance and enforce accountability.
The performance data that was available to MDOC at that time did not appear to
be used to inform agency policymaking. Monthly statistical reports include detailed
data about the numbers and types of medical services provided to the prisoner
population that could have been used for analyzing trends, staff time, and other
costs. This data was reviewed at Medical Audit Committee (MAC) meetings and
quarterly executive committee meetings, but meeting minutes indicate little
emphasis placed upon this data. Furthermore, it is unclear whether any staff
member was monitoring the activity noted in the reports and following up as
needed.
MGT also noted that a number of issues and concerns were discussed in monthly
MAC meeting minutes on a repeated basis during 2010. Meeting minutes often
indicated the same issues were discussed over and over, with agenda items tabled
from month to month, but no final resolution noted. Allowing issues to linger and
remain unresolved for months on end, while noting “tabled” repeatedly on meeting
agendas or in minutes, is not a productive use of meeting time and does little to
address the issues identified. MDOC management, past and present, have
explained that MAC meetings did resolve issues, and that they simply failed to
document the actions taken.
Contracts Not Structured to Help Contain Health Care Costs
MDOC’s contracts with CMS and CorrectRx have not been structured or managed
to maximize cost savings to the State. MDOC’s use of long-term, open-ended
contracts diminishes vendor incentives to continually reduce costs. However,
MDOC’s planned re-bidding of this contract is a good opportunity to bring
competitive pressures to bear to reduce healthcare costs. As part of its review,
MGT suggested approaches that MDOC could incorporate into a new RFP with
the goal of better containing costs. OPEGA reported on these suggestions in an
Information Brief published April 2011. (See Appendix B).

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MDOC’s contracts with
CMS and CorrectRX have
not been structured to
maximize cost savings to
the State. In addition, the
long-term nature of those
contractual relationships
has diminished vendor
incentives to continually
reduce costs.

MGT suggested several
cost containment
strategies that could be
incorporated into MDOC’s
next RFP and the resulting
health care services
contract(s).

There are two primary cost drivers in the MDOC healthcare contract: off-site
treatment costs and staff costs. The key to generating cost efficiencies in
management of off-site services is to shift some risk to the vendor, allowing it the
opportunity to increase profitability if service costs decrease. If, for example, a
vendor is not only responsible for managing off-site hospitalization care, but is also
made responsible for the cost of that care, that vendor will have an incentive to
aggressively manage cost. As a result of competition, some of these cost savings
will be passed along to the State in the form of an overall lower bid for off-site
treatment costs. To assure that these cost reductions reflect increased efficiency
and not reductions in service levels, active management of the contract and
oversight of the vendor by MDOC is necessary. Providing vendors with
opportunities to achieve savings through their performance will also increase
competition for these contracts, as they become potentially more profitable for
more companies.
On the staffing side of the contract, the MDOC-specified staffing plan establishes
clinical staffing levels that are high relative to those of many other state correctional
systems. There are many factors unique to Maine’s correctional system and public
health that may account for this. However, allowing vendors to propose alternative
staffing plans to meet designated contract service levels could produce more
efficient staffing allocations, possibly producing significant medical contract staff
savings for the MDOC.
Finally consolidation of the pharmacy contract into the healthcare management
contract would simplify administrative oversight and would vest financial
responsibility for pharmaceuticals with the organization responsible for supervising
the prescription of these drugs, significantly improving incentives for cost control.
While there has been no independent research into the relative cost impact of
different managed care approaches to correctional health care management, the
widespread use of the approaches outlined above suggests that states have found
them beneficial in controlling costs.

Recent Changes in MDOC’s Health Care Administration ――――――
OPEGA met with the Department of Corrections’ new health care services
administrative team in September 2011 to again discuss the reportable issues from
this review and actions that would be taken to address them. OPEGA learned that
significant organizational changes affecting roles and responsibilities for
administering health care services contracts are underway. In addition, the
prevailing philosophy regarding provision of health services to prisoners and
oversight of health services contractors has changed significantly.
Changes in MDOC’s Organizational Structure
Since January 2011 there have been substantial changes in MDOC’s administrative
layer which impact the administrative oversight and monitoring of health care
services. The new Commissioner of MDOC appointed a new Associate
Commissioner and also made structural changes to the central office positions
responsible for health care services contracts and service delivery.

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Since January 2011,
substantial changes have
been made in the MDOC
administrative positions
responsible for overseeing
health care delivery. The
changes are intended to
streamline
communications, improve
monitoring of contractors,
promote contractor
accountability and resolve
issues in a timelier
manner.

The position of Health Care Services Director, which had responsibility for the
administration of health care contracts, has been eliminated. The previously
existing position of Health Care Services Coordinator continues to serve as the
direct liaison between MDOC management and the CMS Health Services
Administrators at each correctional facility. That position has been reclassified,
however, and now also has direct responsibility, and the requisite authority, for
oversight of CMS and CorrectRX performance and compliance with standards and
policies, as well as for the resolution of health care issues at each facility. The
Coordinator now reports directly to the MDOC Associate Commissioner and is
also functionally overseen by MDOC’s Clinical Director. The Clinical Director,
who also reports to the Associate Commissioner, heads up the entire clinical area
and serves as a bridge between the medical and mental health services being
delivered.
The employee who has filled the position of Health Care Services Coordinator for
the past 3 years described several ways in which she is now empowered to deal with
contractor performance issues and health care complaints or grievances. For
example, she is now allowed to:
•

ask questions of the contract staff or investigate complaints and grievances
on her own authority; and

•

communicate directly with MDOC’s Clinical Director, the Corizon
(formerly CMS) Regional Medical Director and the CorrectRX Director of
Medicaid Management without those communications being funneled
through the MDOC Health Care Services Director.

She explained that the simplified lines of communication allow health care issues to
be resolved in a more coordinated and timely way. She also noted that having the
authority to make inquiries and investigations has been beneficial in monitoring the
contractors’ performance and increasing accountability. MDOC’s new Associate
Commissioner reported that monthly calls are now being held that include herself,
the MDOC Commissioner, the Health Care Services Coordinator and the
Directors at both CMS and CorrectRX so they can cooperatively discuss MDOC’s
expectations and issues that need to be addressed.
MDOC is also hiring a Resource Administrator to assist in administration of the
new health care services contract(s) by providing financial oversight and supporting
the RFP process. The Resource Administrator will report to the Manager of
Correctional Operations who reports to the Associate Commissioner. Once the
contract is in place, this position will be responsible for monitoring and auditing
the financial aspects of the health care delivery contracts, as well as some quality
assurance efforts. An example of planned assignments is developing dashboard
reports on utilization and complaint data that will allow MDOC to better monitor
contractor performance, and identify and respond to emerging issues and trends
that affect quality and cost of services provided. MDOC expects that the Health
Care Services Coordinator and the Resource Administrator will work closely
together in monitoring contractor compliance and performance.
Prior to the initiation of this review, another issue related to organizational
structure and staffing had come to OPEGA’s attention. OPEGA had received
complaints about difficulties arising from contracted health services staff in MDOC
facilities working with, and supervising, a small number of remaining State health
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care employees. MGT observed this issue in its review as well, and recommended
MDOC seek to transition all health care positions to contract staff to avoid the
confusing commingling of contract and State employees. MDOC’s new health care
administrators also recognized this as a problem and the upcoming RFP will
require that the contractor provide all staff. At the time of this report, MDOC was
moving to eliminate the remaining State health care positions through attrition.
Four State positions, two each at LCYDC and MSP, currently remain and will be
phased out by the time the new contract is established.
Changes in Philosophy on Services Provided

Since June 2011, MDOC
has adopted a philosophy
of providing only medically
necessary care. Goods and
over-the-counter
medications previously
prescribed only to improve
prisoner comfort will now
have to be purchased by
prisoners at facility
canteens. Medical
procedures will likewise be
limited to those deemed
medically necessary.

The intent is to reduce
costs, bring Maine more in
line with services provided
in other states, and bring
efficiencies to
administrative and service
delivery processes.

As MDOC’s new administrative team began reviewing medication and prescribing
practices, it learned that Maine had significantly more prescriptions for certain
medications and items than other states. They attribute this in part to MDOC’s
historical practice of allowing prisoners to receive prescription items or procedures
that were “comfort measures” not truly required to treat any medical condition to
the acceptable standard of care.
New Balance sneakers are an example of comfort goods prisoners had been
receiving through prescription. OPEGA had been told, by a source familiar with
the health care being provided at one facility, that prisoners who found the
standard issue sneakers uncomfortable because of their width frequently succeeded
in getting prescriptions for the more expensive New Balance sneakers. MDOC’s
review confirmed this practice. Examples of other comfort items provided by
prescription include over-the-counter pain killers, such as Tylenol or Advil, and
skin creams or baby powder.
Since June 2011, MDOC has adopted a new philosophy of providing only
necessary medical care. Under MDOC’s new philosophy, prisoners will still have
access to many comfort items formerly provided which are over-the-counter in
nature (such as skin creams), but will now need to purchase them from facility
canteens. The new administrators say covering the cost of care that is not medically
necessary is no longer sustainable as MDOC seeks to be increasingly cautious with
its General Fund dollars. MDOC reports that each prisoner’s record was reviewed
by a medical doctor to assure that prescriptions were continued for any medically
necessary items. In addition to reducing costs, MDOC also expects that limiting
prescribed items will improve the efficiency in distributing medications to
prisoners, i.e. shorten the pill lines, and reduce the administrative burden of related
documentation in prisoners’ files.
MDOC’s new philosophy will also be applied in determining what medical
procedures are provided for prisoners. Knee replacement surgery is an example of
a procedure MDOC formerly provided, and paid for, that may no longer be
covered unless replacement is necessary for the prisoner to function within the
walls of the correctional facility. Otherwise, the prisoner’s treatment will focus on
alleviating any discomfort associated with the knee condition. MDOC is currently
also re-assessing the medical necessity for prisoner special diets and personal
property like mattresses.
MDOC recognizes that the new philosophy represents a significant shift from past
practice and will likely result in substantial push-back from prisoners, their families,
and advocacy groups. However, the Department feels this change will bring
Maine’s correctional health care services more in line with other states while still

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meeting its obligation to provide appropriate health care to prisoners. The
Department has been taking steps to inform relevant stakeholders about the
changes, including meeting with the Boards of Nursing and Medicine, having
medical providers and administrators present at Town Hall meetings with
prisoners, and reaching out to advocacy groups. The Commissioner and Associate
Commissioner have also been meeting personally with prisoners on their
complaints.

Recommendations ―――――――――――――――――――――――――――――

1

MDOC Should Periodically Verify Contractor Compliance with
Contract Terms, MDOC Policies and Health Care Standards
MDOC has not had sufficient mechanisms for independently determining whether
contractors are providing all services and goods specified in the contract at the
agreed upon levels of quality and cost. The health care services contractors have
regularly provided performance reports and reported issues they have to MDOC,
but they have largely monitored themselves as MDOC has accepted this
performance information without periodically verifying it. In addition, in a few
cases where CMS was clearly not fulfilling its contractual obligations, the
Department was reluctant to hold CMS directly accountable by requiring CMS to
become compliant or applying financial penalties where the contract allowed for
them. Instead, the Department appeared to either accept the contractor’s
explanations for the non-compliance, or shared the responsibility for finding
solutions to those issues.
As previously described in this report, MGT had noted CMS compliance issues in a
number of areas including:
• medication administration practices and documentation;
• sick call procedures;
• consistent and appropriate maintenance of medical records; and
• provision of required annual health and dental assessments.
When these issues were brought to MDOC’s attention in January 2011, the health
care services administrators challenged MGT’s evidence on some of the issues
because it was not consistent with what CMS had been reporting to them on its
own performance. MDOC acknowledged, however, that the Department itself had
not been independently auditing prisoner files to determine compliance and,
therefore, lacked any independent information on which to judge either CMS’
reports or MGT’s results.
The exception was compliance with sick call standards and policies which MDOC
and CMS had already identified as an issue. Efforts were already underway to
improve the sick call system by introducing new procedures when MGT was
conducting its work in the fall of 2010. Additional improvements have also been
made by MDOC’s new administration.

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Recommended Management Action:
MDOC should ensure all contracts for health care services are adequately
monitored for compliance with specific contract terms, critical MDOC policies and
relevant correctional health care standards. MDOC should implement a formal
plan for periodically verifying compliance independent of the contractor and
contract staff. Such auditing or testing should be incorporated as a key component
of an overall quality assurance process as described in Recommendation 2. MDOC
should require the contractor to take corrective action when non-compliance is
identified and follow-up to assure the corrective action was effective in correcting
non-compliance issues. MDOC should also assess any penalties allowed under the
contract.

2

MDOC Should Strengthen Quality Assurance System
In addition to the lack of independent compliance monitoring, MGT also found
MDOC had a weak overall Quality Assurance (QA) system. MDOC was not
setting overall performance measures for health care nor collecting and analyzing
data to monitor high risk areas or proactively identify potential concerns. MGT
additionally noted that some identified issues seemed to be persistent, with little
documentation of actions being taken to address them, indicating MDOC did not
have an effective system for resolving issues in a timely way.
A well-designed QA system should include ongoing and systematic monitoring and
evaluation to detect potential weaknesses and provide for the proactive
development of appropriate corrective measures. Key features include:
•

Identifying the services that are most critical in terms of risk and liability,
and that should therefore be closely monitored;

•

Establishing minimum standards of performance for all critical services;

•

Collecting the data required to assess whether those minimum standards are
being met continuously;

•

Developing action plans to address identified deficiencies;

•

Assessing the impact of the actions taken to ensure services have improved
to an adequate level.

Though MDOC has had little in the way of a formal QA system in place, a variety
of potential quality issues have come to the attention of management via staff
complaints, prisoner grievances, or through performance data provided by CMS.
MDOC has, however, often failed to take adequate action to address the root
causes of the issues. They have instead been dealt with on a case-by-case basis, or
referred to the Medical Audit Committee where they appeared to be discussed
month after month with no documented action or resolution.

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Health Care Services in State Correctional Facilities

Recommended Management Action:
MDOC should strengthen its quality assurance plan for health care services, assign
responsibility for analyzing monthly statistical reports and identifying trends, and
review the types of statistics being gathered to determine if other kinds of
information would be of greater use. In addition, responsibility should be assigned
for ensuring action plans are developed to address areas of concern identified
through the QA process with regular follow up to assure the expected actions were
taken. As part of the QA system, MDOC should ensure all health care services
contractors are adequately monitored for compliance as described in
Recommendation 1.

3

MDOC Should Ensure Staff Involved in Health Care Service
Delivery are Sufficiently Trained and Knowledgeable of Relevant
Policies and Standards
CMS’s contract requires that all medical and non-medical staff are thoroughly
trained and understand the content of MDOC’s policies and procedures, as well as
the standards of professional care related to health care services. As discussed on
page 13, however, MGT noted several indications that CMS may not be ensuring
that its staff is sufficiently trained and/or may not be providing all training required
under its contract. These indications included:
•

a lack of documentation to demonstrate CMS had been providing the
training as required;

•

CMS acknowledgement that providing First Aid and CPR Training to all
staff, as required, had been an issue;

•

concern among leaders at facilities visited that CMS staff did not have
adequate knowledge of MDOC’s security policies; and

•

some medical staff being unfamiliar with the language in some policies or
having no knowledge of pertinent documents or their purpose.

MGT also took issue with MDOC’s process for communicating updates in policy
and procedures to medical staff. Hard copies of updated policies are placed into
binders and are available in workplace offices. Simply making policies available,
however, is not sufficient to assure staff familiarity with facility requirements, and is
not consistent with best practices. Medical services staff should receive training on
updated policies and should have a clear understanding of the rationale behind
policy requirements and how the policy language translates to procedures at each
facility.
Recommended Management Action:
MDOC should take steps to reinforce and ensure a mutual understanding of policy
content among all affected parties in the organization, including contract staff. It
should also hold its health care services contractor responsible for all training
required under the contract, and should require the contractor to provide
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Health Care Services in State Correctional Facilities

documentation demonstrating when the training occurred, what topics were
covered, and who was in attendance. A training file for each staff person to
document whether and when they have received their annual policy update training
and other required training should be kept.

4

Medical Records Should be Maintained Consistently Across the
Correctional System
MGT noted prisoner medical records were not maintained consistently across
MDOC facilities and some medical records did not appear to be updated when
health services were provided. This lack of consistency made it difficult to
determine whether some prisoners had received the annual health assessments or
dental care required, and complicated the transfer of prisoner records from one
MDOC facility to another when necessary. There was also inconsistency among
facilities in the method used by medical staff to track when prisoners were due for
required services like annual physical and dental assessments. The tracking systems
were primarily manual in nature, allowing for errors that may explain MGT’s
findings that some prisoners had not received their annual physicals and dental
exams.
OPEGA issued an information brief in spring 2011 on a few topics relevant to
managing costs in Maine’s correctional health services (see Appendix B). Those
topics included the benefits of implementing an electronic medical records (EMR)
system. In addition to reducing costs and providing management with better data
for managing health care services, an EMR system would also bring consistency to
health care documentation and the tracking of services that could improve prisoner
care.
The Department has recently decided to pursue getting an EMR independent of
the vendor providing its health care services. As a first step in this direction
MDOC secured a technical assistance grant from the National Institute of
Corrections (NIC) to have a national expert in EMR assess what Maine would need
to consider, and do, in order to transition to electronic medical records. The expert
conducted his work over the summer of 2011 and presented MDOC with a final
report in September.
Recommended Management Action:
MDOC management should hold the health services contractors accountable for
ensuring that medical files at all MDOC medical facilities are organized
consistently, updated to reflect services provided to prisoners, and maintained in
compliance with MDOC procedures and standards. MDOC should also require the
contractor implement an appropriate, standardized system for tracking of required
prisoner health services, i.e. annual physical assessments, for all facilities. An EMR
system would be beneficial to accomplishing these goals efficiently and MDOC
should continue to pursue implementation of an EMR system.

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Health Care Services in State Correctional Facilities

5

MDOC Should Continue to Pursue Cost Containment Strategies
Through New Health Care Services Contract(s)
MDOC soon plans to issue a new RFP for correctional health care services after a
lengthy period developing the RFP over the course of the change in
administrations. OPEGA has reviewed the draft RFP and found it does include a
number of the potential cost containment measures recommended by MGT as
discussed in the OPEGA Information Brief in Appendix B.
Whether the Department is able to realize reduced costs as a result of this RFP
depends, to a large extent, on what it receives for bids, how those bids are
evaluated, and also on how the final contract for services is crafted to ensure all
proposed cost savings are achieved. The Department plans to evaluate bids and
select a vendor in the early spring of 2012 for a new contract starting on July 1,
2012.
In addition to seeking to contain costs via its new RFP, the Department has also
taken some steps to contain costs with its current vendors for the current fiscal
year while the RFP process is underway. The CorrectRx contract has been flat
funded over the last year, except for a small increase to cover the cost of a new
service and an amount required to cover cost overruns from the prior year. The
CMS contract has been reduced by $850,000 over the prior year and has also been
amended to introduce a risk-sharing funding formula for off-site care. Under this
new formula, the Department allows $1,640,000 for CMS’s provision of off-site
care and will only cover 50% of any off-site care exceeding that amount. If the
actual cost of off-site care is less than $1,640,000, the contract specifies CMS must
return 75% of the remaining funds to MDOC. The other 25% is available to CMS
as an additional profit and is intended as an incentive for containing costs.
Recommended Management Action:
OPEGA recommends that MDOC follow through on its plans to issue an RFP
and establish a new contract by July 2012 incorporating cost containment strategies
where reasonable. Once the contract is finalized, the Department should report
back to the Legislature’s Joint Standing Committee on Criminal Justice and Public
Safety on what cost management measures are contained in the contract and how
they can be expected to affect overall prisoner health costs. Finally, MDOC should
monitor its new vendor(s) closely, as outlined in Recommendations 1 and 2, to
ensure that all expected cost containment measures are implemented effectively
and that all cost savings due to the Department are captured.

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Health Care Services in State Correctional Facilities

Agency Response――――――――――――――――――――――――――――――
In accordance with 3 MRSA §996, OPEGA provided the Maine Department of
Corrections an opportunity to submit additional comments on the draft of this
report. The new administration has been developing solutions to address the issues
raised and other areas for improvement that have since been identified. Actions
MDOC expects to take specific to the recommendations in this report are
discussed below.

1

MDOC Should Periodically Verify Contractor Compliance with Contract
Terms, MDOC Policies and Health Care Standards
The new position of Resource Administrator has recently been filled and will be
monitoring contractor compliance with fiscal components of the contract. That
monitoring is expected to include regular review of compliance with staffing
provisions and monthly analysis of contractor bills. The Resource Administrator
will attend the monthly calls with Corizon and Correct Rx and will work closely
with the MDOC Health Services Coordinator.
The MDOC Health Services Coordinator is responsible for monitoring contractor
compliance with clinical aspects of the contract. She will make quarterly on-site
visits to each correctional facility for the purpose of conducting medical record
reviews. These reviews will include audit and examination of various sections of the
prisoner medical records for completeness and adherence to MDOC health care
policy. A random sampling of offender medical records will be audited at each site
during the quarterly visit. A representative of the MDOC Quality Assurance Team
will accompany the MDOC Health Services Coordinator on these site visits and
gather performance measurement data on the same medical files.
The data obtained during quarterly site visits will be compiled into a written report
and disseminated to the vendor for review. All quarterly reports will be compiled
for ongoing monitoring and trend analysis and data will be used to make future
decisions regarding prisoner medical services. As necessary, corrective action plans
will be required of the vendor to address any deficient areas identified by auditing
or any other means. This monitoring process will become effective January 2012.

2

MDOC Should Strengthen Quality Assurance System
MDOC central office staff is currently tracking medical requests and concerns that
come into central office using a spreadsheet log. Additionally, monthly meetings are
being held between MDOC central office staff, Corizon and CorrectRX to monitor
costs and services, and discuss challenges and plans for improvement.
The MDOC Commissioner is also in the process of establishing a new Quality
Assurance Division within the Department. The primary mission of the QA
Division will be to develop and implement a nationally recognized PerformanceBased Management system for corrections. The system includes a whole section on
medical care relevant to many of the issues described in this report and will result
in the regular collection of data that can help MDOC determine compliance and

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Health Care Services in State Correctional Facilities

make informed decisions about prisoner health care. Establishment of the QA
division and how it will interact with regard to the medical contract will be pursued
over the next few months. MDOC is getting technical assistance from the National
Institute of Corrections on this effort. The new QA Director and staff are being
trained by NIC on data collection in November 2011 and will begin implementing
a data collection process for the entire adult system. The timeframe for
implementation is somewhat dependent on the availability of resources from the
Office of Information Technology.

3

MDOC Should Ensure Staff Involved in Health Care Service Delivery are
Sufficiently Trained and Knowledgeable of Relevant Policies and Standards
New policy and policy changes are already reviewed with staff. However, MDOC
will seek additional assurance that all updated policies are available to staff through
the new QA methodology. Each facility has a Manual of MDOC policies pertaining
to medical services, and medical department staff has access to the Manual. At each
quarterly site visit, the MDOC Health Services Coordinator will review the MDOC
Medical Policies and Procedures to ensure that the most current policies and
procedures are being utilized at each facility.
Additionally, at least one MDOC policy pertaining to medical services will be
reviewed at medical department staff meetings at the respective facilities each
month. A MDOC policy pertaining to medical services will also be reviewed at
each Medical Audit Committee meeting at each facility. Those reviews are to be
reflected in the minutes of each meeting.

4

Medical Records Should be Maintained Consistently Across the Correctional
System
In September 2011, the National Institute of Corrections provided a consultant to
review the Maine Department of Corrections health care system and the potential
benefits of transitioning from a paper-based system to an electronic health record
system. The consultant’s report recommends that MDOC pursue implementing an
electronic medical record (EMR) system to increase efficiencies and standardize
health care records and tracking systems. For several reasons, MDOC would prefer
to pursue the purchase and implementation of an EMR system that is independent
from whichever vendor may be selected to provide the correctional health care
services. There is no funding available for an independent EMR system, however,
and, therefore, the MDOC will consider an EMR system in the next RFP for health
care services that is soon to be issued.
If an EMR system does not get implemented, the MDOC will continue to monitor
and improve medical records and tracking of required medical service as part of the
on-going compliance and quality assurance review processes described in Actions 1
and 2 above.

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Health Care Services in State Correctional Facilities

5

MDOC Should Continue to Pursue Cost Containment Strategies Through
New Health Care Services Contract(s)
As previously described in Recommendation 5 on page 22, MDOC intends to
explore several cost containment strategies through the upcoming RFP for health
care services and has also taken recent steps to reduce costs associated with current
contracts. Those steps include amending the current contract with CMS to
introduce a risk-sharing formula for off-site care and holding monthly meetings
with Corizon and CorrectRX where the focus is on cost savings opportunities.
These steps have proved extremely beneficial over the last 3 months as shown by
these statistics (comparing to same time period as last year): Emergency room visits
- down 88% with no admissions during the past three months; Inpatient days –
down 66%; Outpatient Referrals – down 55%; RX costs (July-Oct 2011) – down
18%.

Acknowledgements ――――――――――――――――――――――――――――
OPEGA would like to thank the management and staff of the Maine Department
of Corrections for their cooperation during this review.
Additionally, we appreciate the technical expertise and perspective that MGT of
America, Inc., brought to this project.

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Appendix A. Scope and Methods

Health Care Services in State Correctional Facilities

Early in this review, OPEGA decided to contract with a consultant to perform the majority of work on this project in
order to benefit from the expertise of auditors that have reviewed medical services in correctional settings across the
country. OPEGA selected MGT of America, Inc. through a competitive Request For Proposals process. MGT
completed the majority of their work during the fall of 2010.
To obtain an understanding of Maine’s correctional health care system, MGT reviewed relevant laws, regulations, and
policies and identified those that were applicable and significant to the audit. In doing so, MGT reviewed MDOC’s
policies and procedures related to contracted services. Also, MGT obtained documentation from MDOC
headquarters and facilities. Finally, MGT interviewed MDOC and CMS staff to assess their roles and responsibilities
with regard to health care services in MDOC.
To develop an understanding of service delivery issues and assess MDOC’s contract monitoring processes, MGT
examined monitoring terms and practices, quality assurance methods, claims processing procedures, and internal
reviews. Also, MGT assessed contract administration, contractor responsiveness, MDOC operations, resources,
external issues, and availability of medical professionals.
To determine the level of compliance with key contract terms, MGT reviewed performance, contract staffing plans,
penalties for vacancies, performance metrics, performance standards, and management reporting. MGT also
performed detailed testing of a judgmental sample of the populations at the two largest adult facilities and one
juvenile facility to determine compliance levels with contract terms and accepted standards of care.
MGT weighed the data and information gathered against criteria including known best practices, industry standards,
benchmarks to comparable peer jurisdictions, and established federal and state legal requirements and departmental
goals and objectives.
Specific work conducted by MGT during this review included:
• Interviewing state and contracted managers and staff responsible for each facet of the delivery and
administration of Maine’s correctional health care services, as needed;
• Reviewing MDOC’s and contractors’ documented policies and procedures concerning the delivery and
administration of health care services;
• Reviewing MDOC’s contracts for medical and pharmaceutical services, including contract extensions and
amendments, their approvals, and the purpose of each revision since 2004;
• Conducting site visits of the nine correctional facilities, inspected the healthcare facilities, and analyzed
operations with respect to the provision of health care services;
• Interviewing the CMS regional manager and medical directors (outgoing and incoming);
• Reviewing MDOC healthcare reports, reports of various committees and working groups in Maine, relevant
audits, planning documents, as well as reports and meeting minutes that resulted from regular and special
meetings related to MDOC’s health care services;
• Reviewing laws, regulations, medical standards, and healthcare best practices;
• Reviewing healthcare performance reports, metrics, and statistical reports;
• Performing detailed review of a judgmental sample of prisoners’ medical files and medication administration
reports at the two largest adult facilities (MCC and MSP) and one youth facility (LCYDC) to determine
compliance with key contract provisions;
• Reviewing extensive documentation related to site-specific practices, policies, procedures, reports, grievances,
training records, co-pay tracking, contract monitoring, and other health care administration and delivery
documentation for MCC, MSP and LCYDC;
• Reviewing medical-related prisoner grievances and the grievance processes;
• Evaluating MDOC’s current and planned practices related to elderly prisoners and end-of life health care
services and comparing MDOC’s population to national correctional healthcare trends;
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Health Care Services in State Correctional Facilities

•
•
•
•

Analyzing MDOC’s methods for procurement of medical and pharmaceutical services and methods for
contract oversight and administration;
Reviewing contractor invoices and billing data for fiscal year 2009-10 and testing 100 percent of all invoices
and statements during the year for appropriate review, approval, and calculation of billing paybacks and
administrative penalties;
Evaluating the information technology systems and manual record-keeping systems in place at MDOC’s
healthcare facilities; and
Requesting data from MDOC’s prisoner record management information system and human resources
system.

MGT presented OPEGA and MDOC with a draft report of results and recommendations in December 2010. Since
that time OPEGA has been working with the Department to understand the root causes of some of the issues
identified by MGT and to discern what actions the Department planned to take to resolve the issues. These
discussions with management took much longer than is typical because of the significant changes occurring at the
Department between January and August of 2011. Over that period of time, MDOC’s management team changed, as
did its response to MGT’s findings. As a result, OPEGA staff spent additional time meeting with management and
reviewing documentation to understand and confirm the changes being made within the organization. This report
has been structured to incorporate all of the most current information about the status of health care services within
Maine’s correctional system.

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Appendix B. OPEGA Information Brief

OPEGA

Health Care Services in State Correctional
Facilities: Opportunities to Contain Costs
and Achieve Efficiencies

Information Brief
Revise Contract Structure, Terms and Conditions
Purpose

Overview

OPEGA has a review of health
care services in Maine’s
correctional system in progress.
The review is primarily focused
on the performance of key
contractors MDOC uses to
deliver health care services, and
MDOC’s monitoring of those
contractors. OPEGA engaged
MGT of America, a national
consultant with expertise in the
provision of health care services
in correctional facilities, to
assist with this review. The final
report is expected later this
spring.
This Information Brief discusses
some of the specific
suggestions MGT made for
steps Maine could take to
contain future costs and
achieve efficiencies, while
maintaining or improving the
quality of care available to
prisoners.
MGT shared its suggestions with
MDOC, which is interested in
pursuing them. Implementation
will require planning and action
that should begin immediately if
the State desires to reap
benefits within the next several
years. The Legislature may wish
to discuss these opportunities
with MDOC during this
legislative session in the context
of the Department’s priorities
and any associated resource
issues.

April

2011

No SR-MEDSERV-09

Maine’s Department of Corrections (MDOC) operates nine correctional facilities—two for
juveniles and seven for adults—housing more than 2,000 prisoners as of December 2010.
Each facility offers some health care services, and when a facility is not able to provide the
level of care a prisoner requires, the prisoner may be transported off site to another
correctional or health care facility to receive the necessary care. Although a few State
A
employees
still participate in the delivery of care, most services are provided through
contracts with third parties. A summary of the services provided at each facility, and by
which contractor, is provided in Table 1.
Table 1. Summary of Health Care Services and Providers by Correctional Facility
ADULT FACILITIES

MEDICAL

DENTAL

PHARMACY

Bolduc Correctional Facility

CMS / MDOC

CMS

Correct Rx

Central Maine Pre-Release Center

CMS

CMS

Correct Rx

Charleston Correctional Facility

CMS

CMS

Correct Rx

Downeast Correctional Facility

CMS / MDOC

CMS

Correct Rx

Maine Correctional Center

CMS

CMS

Correct Rx

Maine State Prison

CMS / MDOC

CMS

Correct Rx

Women's Reentry Center

CMS

CMS

Correct Rx

JUVENILE FACILITIES

MEDICAL

DENTAL

PHARMACY

Long Creek Youth Development Center

CMS / MDOC

CMS

Correct Rx

Mountain View Youth Development Center

CMS

CMS

Correct Rx

Legend: CMS = Correctional Medical Services; MDOC = Maine Department of Corrections
Source: Information provided by the Maine Department of Corrections.

As shown in the summary, Correctional Medical Services (sometimes supported by MDOC
staff) provides all medical and dental care, and Correct Rx provides all pharmaceutical
services. Contracts with these entities are supported only by General Fund resources and
amounts expended for FY 2010 totaled $12.0 million under the Correctional Medical
Services (CMS) contract and $2.7 million for Correct Rx. MDOC has contracted with CMS
since 2003 and Correct RX since 2007.
MDOC’s use of long-term, open-ended contracts diminishes vendor incentives to
continually reduce costs. In addition, MDOC’s contracts with CMS and Correct Rx are
“cost-plus” contracts. In these types of contracts the vendor is reimbursed at a specific rate,
which includes actual costs for staff and services provided plus an amount to cover vendor
overhead and profit. Cost-plus contracts are generally used in systems where costs are very
well-defined and/or fixed, with little opportunity for cost savings. MGT of America
(MGT), the correctional health care expert OPEGA hired for this review, noted two
problems with this approach for contracting health care services from the standpoint of
controlling costs:

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Information Brief – Health Care Services in State Correctional Facilities

1. The State assumes all of the risk in managing health care costs and there is no financial incentive for the
vendor to achieve efficiencies or reduce spending. Because the vendor is simply reimbursed for actual
staffing and off-site care costs, they receive little direct benefit from any efforts to manage utilization and
reduce health care spending. Whether hospitalization costs run high, or are instead below projections, the
vendor simply passes these costs along to the State. One of the primary benefits of privatization is for the
State to minimize its risk for escalating costs by shifting responsibility for management of those risks to
vendors with very specific expertise in correctional health care management. Under the cost-plus approach,
the vendor assumes no risk and opportunities to achieve efficiencies often expected from privatization of
correctional health care are minimized.
2. Cost-plus contracts increase the administrative burden on the vendor, which passes additional processing
costs back to the State. The burden is also larger on the State directly, due to workload associated with
confirming actual vendor spending and reconciling payments against those expenditures to ensure the actual
cost of care was paid to the vendor. In an alternative arrangement where the vendor’s compensation is
fixed, administrative costs like reconciliation are avoided.
Contract structures and terms that put the vendor at risk of losing money if costs exceed a certain level, or
conversely provide an opportunity to increase profits if expenditures are reduced, are more likely to encourage
effective cost management – particularly when vendor risk is allocated to those areas where the vendor’s experience
and expertise can most effectively be leveraged. MDOC’s current contracts with CMS and Correct Rx do not
include these kinds of risk sharing provisions and do not provide substantial financial incentives to aggressively
control costs. However, the term of the CMS contract expires at the end of June 2011 and the Department has been
preparing to issue a Request for Proposal (RFP) for correctional health care services. The upcoming bid of this
contract is a good opportunity to bring competitive pressures to bear to reduce health care costs. MDOC has plans
to incorporate some of MGT’s suggestions, as described below, into the RFP.
Opportunities for Improvement
MGT of America noted a number of proven contracting approaches that could contain future costs or generate cost
savings in correctional health care services. The key to most of these approaches is to shift risk to the vendor,
allowing them to increase their profitability as they decrease health care costs. Generally these approaches require
vendors to bid a fixed price to cover the cost of health care services provided outside of correctional facilities.
Establishing a fixed price incentivizes the vendor to effectively manage utilization, negotiate discounted rates for
service and audit bills to achieve maximum efficiency in providing service. Providing vendors with opportunities to
reduce their costs through their own performance should also increase competition for these contracts as they
become potentially more profitable for more companies.
Alternative approaches MGT has observed as providing the most savings assign vendor risk to relatively predictable
areas, as well as to those areas where vendor experience and expertise can yield savings. For example, the contract
could require the vendor to assume responsibility and financial risk for managing and controlling off-site care costs,
but also establish catastrophic caps. These caps can be used to put a ceiling on vendor responsibility for individual
case cost, or to share the cost of care beyond a certain level. Catastrophic caps are beneficial because they can
eliminate the vendor’s built-in cost for stop loss insurance by reducing the vendor’s overall risk for high cost cases.
This allows vendors to more effectively price routine care and avoids additional risk premium costs to cover the
major cases that might, or might not, occur.
Other costs, such as those associated with HIV, Hepatitis C, Factor VIII and IX, and organ transplants, can be very
unpredictable. Vendors who must pay these full costs typically build a risk premium into their contract bid to cover
these potential costs. The State could, instead, take responsibility to pay these costs in full, outside of the vendor
contract. This allows the State to pay only the costs that actually arise rather than pay higher on-going rates to cover
a built in premium based on potential costs in these areas.
OPEGA observed that a contract that shifts risk to the vendor, and subsequently allows the vendor increased profit
opportunity, could potentially entice a vendor to make decisions that would increase profits, but be detrimental to
the quantity and quality of services provided to prisoners. The best control to prevent this from happening is

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Information Brief – Health Care Services in State Correctional Facilities

prudent contract administration and a strong system for monitoring vendor performance. MDOC would need to
strengthen its current monitoring procedures to ensure quality of care under a non-cost plus contract.
Aside from recommending a move away from cost-plus contracting, MGT also noted a number of measures that
have worked in other states to better manage costs and increase efficiencies, regardless of whether a cost-plus, or
some alternate contract model is used. These approaches include:
•

Set staffing reimbursement rates at 90 percent of contract requirements. CMS is currently paid each month
on the basis of the full amount of staff hours required in the contract. There is then a monthly
reconciliation process to determine what credits are due to MDOC for contracted hours that were not
provided. According to the CMS regional manager, CMS’ accounting staff spends significant time preparing
monthly reports based on actual time records, comparing on-site staff time to the contract staffing
requirements. These calculations are then checked by MDOC staff. This monthly reconciliation can be quite
detailed and time-consuming given the amount of vacancies present at any given time and normal staff time
off. An alternative approach recognizes that staff fill rates seldom approach the contracted level and reduces
monthly upfront payments to the vendor to recognize that. A number of systems pay vendors on the basis
of 90 percent of contract hours provided, then just reconcile once a year to account for any overages or
underages. The end result is improved cash flow for the Department due to reduced upfront payments, a
simplified reconciliation process, and reduced overhead for both the Department and vendor as
reconciliations are cut from 12 per year to once annually.

•

Consider including requirements for a comprehensive Electronic Medical Records (EMR) system in the
RFP. The cost of these systems has come down in recent years, and acquiring a system through the contract
process allows the cost of the system to be amortized over the life of the contract. MDOC should specify
that any EMR system be non proprietary in nature, be compliant with any federal guidelines and be a system
that is already operational on a large scale. The RFP should also continue to include telemedicine with
requirements that the vendor have experience in developing and conducting those services. MGT has
observed that integration of telemedicine and EMR systems have allowed a number of correctional systems
nationally to dramatically improve the efficiency of service delivery. (See the EMR section on page 6 of this
Brief for further discussion.)

•

Encourage bidders to propose alternative staffing plans. In structuring the RFP, all vendors should be asked
to bid on the same staffing plan. However, MDOC should also request that bidders propose alternative
plans, tied to specific benchmarks of service, that can be used for negotiations. While the staffing pattern
MDOC uses may be appropriate for Maine, vendors with extensive expertise in managing correctional
health care services may have different approaches that could generate savings. MGT also observed that
converting all remaining State health care positions to contract positions in the RFP could be helpful in
addressing administrative issues associated with the joint management of contract and State staff in the
same unit. OPEGA observes that such a conversion would require changes to the Department’s
appropriations and authorized positions and would likely have union contract implications.

•

Consider including pharmacy with medical services as a comprehensive contract. MGT finds that separating
out medical and pharmaceutical services often drives up cost and dilutes accountability. An alternative
model makes the vendor that is responsible for prescribing medication bear the financial consequences and
risks of those prescribing practices. MDOC has had negative experiences with combining these services
under one vendor in the past and believes this is a situation with both pros and cons that should be carefully
considered.

•

Establish a fixed contract term of 3-5 years. A multi-year fixed term contract in this range allows a vendor a
sufficient time horizon to recoup investments in the system, but also retains the benefit of competitive
bidding for the Department.

•

Consider establishment of incentive programs, tied to performance benchmarks, to contain costs in medical
care as well as other related areas such as security and transportation. MGT has found structured incentive
programs are good alternatives to penalty programs, and will often generate improvements in medical
outcomes, greater efficiency in delivery of care and more creative ideas in managing care. The establishment
3

Information Brief – Health Care Services in State Correctional Facilities

of benchmarks for health outcomes is, however, critical to ensure appropriate care is not being
shortchanged to meet incentives. Services that exceed the set benchmarks are rewarded with incentive
payments. Incentives can be readily established for staffing fill rates. Another area where incentives could
be beneficial is off-site care. Adding incentives in this area should motivate the contractor to find ways to
provide services on site, reinforcing such things as telemedicine, chronic disease management, on site
specialty care, and effective infirmary use.
•

Look for vendors with strong utilization management programs. RFPs should require bidders to provide a
full explanation of their utilization management programs and MDOC should assess each program’s
comprehensiveness. RFPs should not specify what should be included in the vendors’ utilization
management programs. Rather, MDOC should look for those programs that have built-in systems designed
to continually improve service management, such as where doctors and other clinical staff consult on and
review cases to bring in multiple levels of expertise. A well designed utilization management program
should help identify and manage high cost areas.

Improve Planning and Care Alternatives for Chronically Ill and Elderly Prisoners
Overview
According to the Bureau of Justice Statistics in 2008, 4.7% of states’ prison populations were 55 years of age and
older. Prisoners in their fifties are often considered geriatric due to their generally poor health and shorter life
expectancy. While the number of these prisoners is small, they present special challenges in the delivery of health
care. The cumulative effects of aging often mean they require more medical services, including costly long-term care.
According to the National Hospice and Palliative Care Organization, end of life care in correctional settings will
become increasingly necessary in coming years. As the number of aging and ill incarcerated men and women
increases, correctional facilities’ methods to manage these prisoners in a humane and cost-effective manner are of
particular importance. In addition, such care is guaranteed under the Civil Rights of Institutionalized Persons Act
(CRIPA) and Americans with Disabilities Act Amendments Act of 2008 (ADAAA).
In November of 2010, MDOC reported 189
prisoners 55 years of age or older in the State
prison population. This group represented 9%
of the total 2,094 prisoners in the population.
Table 2 includes a breakdown of MDOC
prisoners by age group and number of years
until release. At the present time, Maine has no
method of tracking medical costs specific to
geriatric prisoners regarding use of specialists,
types of treatment, durable medical equipment,
health care appliances and medications. As a
result, the exact cost of providing care for this
group is currently unknown.

Table 2. MDOC Population: Age and Years Left Until Release as
of November 19, 2010
Years Until Release

Age

Total

51-55

56-60

61+

< 1 year

38

19

21

78

1 to 3+ years

37

23

28

88

4 to 5+ years

11

4

9

24

6 to 10+ years

11

9

8

28

11 to 20+ years
11
8
8
27
MDOC has few options for providing services
to chronically ill or geriatric prisoners when the 21 to 30+ years
10
3
1
14
care they need is not available at the facility in
>30 years
6
4
3
13
which they are housed. The Department does
have a Medical Supervised Community
Life
7
8
13
28
Confinement Program, which provides for
community confinement of prisoners with
Total
131
78
91
300
terminal, or severely incapacitating, medical
Source: MGT America.
conditions when care outside a correctional
facility is appropriate from a medical and security perspective. When approved by the MDOC Commissioner,
prisoners under this program live in a hospital or other appropriate care facility, such as a nursing facility, residential

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Information Brief – Health Care Services in State Correctional Facilities

care facility, or a facility that has a licensed hospice program. They are essentially under the supervision of the
community facility, but may also be subject to periodic probation type check-ins. Under this program, the
Commissioner also can approve home placement for prisoners that are at end of life and present no risk to others, if
appropriate services can be arranged. Funding for these alternative placements varies according to a prisoner’s
individual circumstances with MaineCare or private insurance.
MDOC reports that, despite a tremendous amount of effort applied toward community placement, making it work
is difficult. Since the Program’s inception, there have been three prisoners placed in alternative settings. One
prisoner was approved for home placement. The prisoner’s overall health condition improved, to the extent the
prisoner was re-assigned to a community facility, reached the end of his sentence and was released. Two other
prisoners were placed in community facilities, but following significant problems both were returned to MDOC
facilities. At present, there are no prisoners in this program.
For those prisoners not suitable for community placement, however, the MDOC often must move them to a higher
security facility where the medical care they require is available. This practice is not uncommon. MGT reports that
many correctional systems tend to concentrate health care services at high security facilities due to the longer stays
and more intensive needs of prisoners at these facilities. However, this ties up valuable infirmary beds available for
treating the remainder of the population and may result in ill or elderly patients being held in a more restrictive (and
therefore more costly) environment than is necessary. The more restrictive environment may also limit prisoners’
access to programs and services that may be required for rehabilitation or which must be successfully completed
prior to consideration for release or community placement. Making special accommodations to continue such
programming for ill or elderly prisoners moved to high security facilities is sometimes possible, but represents yet
another additional cost.
MDOC reports that currently four of the six infirmary beds at the Maine State Prison are filled, due to lack of
alternatives for other appropriate placement, with prisoners who have long term care needs. Many more are also at
risk of needing a bed for long term care. MDOC could be immediately facing a situation where it does not have
enough infirmary beds for those needing long term care and will have to bear the expense of placing prisoners in
off-site hospital beds instead. This situation would also mean there are no infirmary beds to house prisoners who
have short term sicknesses. The Department has also expressed concern about housing the elder population in the
future. Secure bed space, physical plant design, access to programs and services, medications, special diets, distance
to emergency hospital services, and preparation for community re-entry are some of the expected challenges for this
population. MDOC has contacted some other states regarding management of this population, but currently has no
formal short-term or long-term plans to strategically address the issue.
Opportunities for Improvement
MGT suggests that MDOC consider the following actions to ensure appropriate planning and administration of
health care services for chronically ill and elderly prisoners in the future:
1. Review MDOC’s strategic plan and revise accordingly, with specific goals, objectives and strategies listed for
bed planning and health care management of the aging population, using the “right prisoner, in the right
bed, for the right reason” method to utilize the best and most efficient resources.
2. Continue to analyze current data, and gather new data as needed, in order to identify:
• costs of elder care;
• medical and health care conditions most often being treated;
• medications most often being prescribed;
• prisoner demographics including gender, age, most severe crime committed, average length of sentence;
• types of disabilities being managed;
• typical kinds of accommodation requests being received and how those requests are being managed;
• use and management of health care appliances and durable medical equipment including associated
security implications; and
• food service costs related to special dietary needs.

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Information Brief – Health Care Services in State Correctional Facilities

Such information will provide hard facts as a basis for MDOC and the Legislature’s future discussion of this
issue.
3. Review current housing, programs, and staff supervision policies for this population. Evaluate the impact of
ADAAA requirements on management of geriatric prisoners.
4. Conduct a review of end-of-life services and procedures using quality guidelines for hospice and end-of-life
care in correctional settings developed by the National Hospice and Palliative Care Organization and seek
opportunities for technical assistance, if possible. According to MDOC, there is a hospice program at the
Maine State Prison as dying prisoners are most likely to be in the infirmary beds there.
5. Review policies, procedures, and practices related to infirmary care and associated costs.
The Legislature may also want to consider further study of issues surrounding Maine’s geriatric corrections
population. MGT suggests the cost of such a study may eventually be viewed as a small, upfront investment with a
large benefit in the future. Community supervision, housing, ongoing and available treatment programs,
employment, transportation, restitution, and reunification of families are some of the significant topics for
consideration.

Implement Electronic Medical Records System
Overview
MDOC’s current system of record keeping associated with prisoner health care services is mostly manual and varies
from one facility to another. Archival of MDOC’s prisoner health care records appears to be bulky and burdensome
for storage and access. According to MDOC and CMS staff, if a prisoner returns to the custody of MDOC, there is
often a significant delay in researching and acquiring the prisoner’s prior paper medical charts and records from a
central archive location.
This practice is not efficient. It can result in creation of duplicate files and require additional staff effort, thus
driving up unnecessary administrative costs. In addition, MDOC facilities do not have access to digital medical
records used by doctors’ offices and hospitals in the community. This situation makes it difficult to obtain records
for individual prisoners who have received care in non-institutional settings.
Manual records and files also limit the ability to collect and analyze data on health care service delivery that should
be used for effective utilization management, monitoring of contractor performance, planning for the prison
population’s health care needs and tracking costs. Performance-based health care standards also call for collecting,
analyzing, and actively using performance improvement data to foster quality assessment and performance
improvement in all areas of care.
Electronic Medical Record (EMR) systems offer users several benefits in the correctional setting. Centralizing the
data allows access at any time, from any location by approved medical professionals. Difficulty in reading the
handwriting of others is eliminated. Patient privacy is maintained. Required field completion and a defined sequence
for entering notes about patient therapy, treatment and medication reduces errors and makes patient records more
consistent. A link to pharmacy services is possible that could improve medication management, as well as links to
daily, real-time prisoner moves, allowable property lists noting approved health care appliances and durable medical
equipment, and information about special dietary needs.
In addition, paperless record keeping contributes to storage space efficiency. With appropriate backup systems,
historical data can be maintained indefinitely and valuable physical space that was previously used for bulky paper
files can be repurposed. When agencies opt for “certified electronic health record technology,” systems may be
compatible with jails and hospitals in the community. The end result is administrative efficiencies, improvements in
record keeping, and valuable stored data that can be accessed at a moment’s notice in order to report on trends,
demographics, housing or security issues, and many other topics that may be of use to legislators and management
in considering issues of prisoner health care.

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Information Brief – Health Care Services in State Correctional Facilities

MGT reports that correctional systems in other states have adopted EMR systems, and in some cases have leveraged
health care contracts to introduce the needed technology. However, though the value of such systems is evident, the
initial cost can be high, depending upon the size of the correctional system and functionality required. MGT notes
that states are often able to negotiate with vendors to have the cost of EMR implementation amortized over the life
of the vendor’s contract so the State does not have to absorb the full cost in one year.
Aside from financial investment, implementing an EMR system can also take a substantial investment of time and
energy on the part of the Department. For an implementation to be optimally successful, the correctional system
must prepare by undertaking a review of all processes, and reengineering them where necessary, to ensure
procedures mesh efficiently with the new EMR system and maximize its effectiveness. This process assessment
requires the involvement of stakeholders at all levels in the organization and, if substantial process change is
necessary, can also result in a need for significant training hours to ensure all staff are adequately prepared to adhere
to new procedures.
MDOC has been interested in implementing an EMR system for some time and, in fact, has previously pursued
obtaining this technology through an arrangement with a third party as the system CMS offered was not suitable.
Those plans were disrupted, however, and until recently MDOC had not renewed efforts to get an EMR system in
place. According to the Department, an EMR Task Force was activated a few months ago and is actively seeking the
most cost effective medical management system. The National Institute of Corrections will be providing MDOC
with assistance and guidance in this effort.
Opportunities for Improvement
The effective use of a functional and well-designed EMR system can drive improvements in the quality and
efficiency of health care services delivered in Maine’s correctional system, potentially encompassing both State
institutions and county jails. MDOC, with the involvement of the State’s Office of Information Technology, is again
actively pursuing the selection and implementation of an EMR system. This system should be proven, compliant
with federal guidelines and compatible with other systems, both public and private, with which it needs to, or
should, interface.
MDOC could explore the acquisition of such a system through the upcoming RFP process for medical services by
soliciting bidders’ proposals on an EMR system as well as increased use of telemedicine. Any EMR system
implemented by a MDOC vendor should be required to be non-proprietary in nature so MDOC maintains both the
system and its future ability to bid out health care services. According to MGT, the integration of telemedicine and
EMR systems has dramatically improved the efficiency of service delivery for a number of states’ correctional health
care systems. Consequently, MDOC should also consider requiring vendors bidding on the new RFP to have
experience in developing and conducting actual telemedicine services.
The Department will likely need the Legislature’s support of the initiative to implement EMR as it could represent a
significant investment of both human and financial resources. The Legislature can help assure that this effort
remains a priority for MDOC and that adequate resources are appropriated and well spent by the Department.

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