Middlesex Sheriff s Office NCSL Atlantic States Fiscal Leaders Meeting Presentation Tackling the High Cost of Prison Health Care Peter J. Koutoujian, Sheriff Saturday, February 25, 2017
The Middlesex Sheriff s Office What we do and who we serve Snapshot of Middlesex County: Population is 1.55 million (23% of state population) 54 cities and towns covering 817.82 sq. miles -- one of the largest counties in the country Courts = 20 (includes probate, family & juvenile) 92% of residents (ages 25+) have high school degrees Snapshot of the Middlesex Sheriff s Office on Feb. 13, 2017* Care, Custody & Control of 1023 inmates 458 Sentenced (convicted and serving 30 months and under) 565 Pre-Trial Detainees (charged, awaiting trial) *Number does not include females who we transport to and from court from MCI-Framingham. Our FY2017 budget is $66.7 million with 78% of that employing 675 essential officers and support staff. 2
WHY GOING TO JAIL CAN SAVE YOUR LIFE How we use our window of opportunity to address the factors that led to incarceration, including drug use Individuals are away from toxic living environment Have access to medical care 24/7 Health Services Unit had 178,744 contacts in 2016 We are the largest mental health facility in Middlesex County many diagnosed with mental illness for the first time while incarcerated. Traditional health care barriers are eliminated Access to health insurance Access to a primary care physician Financial barriers to receiving care No distractions or obstacles, such as lack of transportation or work/family obligations Treatment beds are available Medical staff specializes in substance use treatment Access to programs and services that address addiction 3
Medical Budget Overview Medical costs (including medical employee payroll) is a total of 9% of the MSO operating budget. The unpredictability of health care costs for inmates continues to be one of our biggest budgetary challenges. Inmate health care can range from optometry appointments to treatment of severe medical conditions. Pharmaceutical and medical costs are difficult to budget from year to year and continue to drastically impact our operating budget. Mental health pharmaceuticals are costly and approximately 23% of our overall medication expenses. The MSO Mass Health initiative was implemented in fiscal year 2015 and has resulted in a total billed savings of $1,280,591 (fiscal year to date billed savings is $494,808). The MSO is required to provide medical transportation and coverage for inmates at hospitals. This continues to not only be a fiscal challenge, but is also an operational staffing challenge. 4
FY17 Estimated Budget Breakdown Medical Payroll $2,709,675 Hospital Coverage and Transportation $646,016 Medical Services and Supplies $ 260,000 Health Care Services (hospitals, CPS) $1,680,650 Pharmaceuticals and services $517,145 ($120,000 estimated psych meds) Total $5,813,486 5
The Impact of the Opiate Epidemic 80% of inmates self-identify as having a substance use disorder. 42% new intakes in January received detox protocols. 78% of intakes in January received detox protocols for an opioid combination. 6
The Link Between Substance Use and Crime Almost half of those in our custody (42%) have a drug addiction so severe they need to be detoxed immediately. 87 27 24 7 Alcohol Opioid/Narcotic Benzodiazapam Polysubstance (opioid) Note: December 2016 raw detox data: 145 men total, 76% involving Opioids 7
Innovative Programming MATADOR Goals and Overview Use the window of opportunity to tackle drug addiction by: Increasing Medication Assisted Treatment (MAT) to the most vulnerable and at risk populations. Combining MAT with counseling and MSO critical casework follow up. Utilizing health insurance as a re-entry tool to improve access to and continuity of health care. Tracking performance measures to determine program success. Robust, real-time data provides direction and correction MATADOR program staff work collaboratively with Sheriff s Office researchers to identify data trends and provide critical, timely feedback to consistently monitor program performance. Allows MATADOR team to quickly adjust to the needs of the program and it s participants. Personal Connection and MSO Staff Follow Up is Key After their release, participants are not legally obligated to maintain contact with the program staff (unless under probation or parole supervision). Building a rapport and establishing trust with participants is a key component. How do we define success? MATADOR staff communicates with participants for six (6) months post release, allowing for the oversight of injections and program compliance. At the six month mark, participants are well into their reintegration back into the community, have established routines and the continuity of care is established. 8
One Year MATADOR Snapshot: A Public Safety Perspective 17% overall recidivism rate (primarily violations of Probation/Parole) 6% Drug-related recidivism rate. 45% 26% Completed Active Inactive Fail 23% 1 confirmed reoffender from this population. 6% 9
How do we pay for our most aggressive drug treatment program? Using Non-Operational Funding Middlesex Sheriff's Office A-Pod Substance Use Programming FY15 Expenditure Breakdown 7.098% 19.025% Department of Public Health Substance Abuse Grant Direct Inmate/Canteen Expenses Residential Substance Abuse Treatment (RSAT) Grant 73.877% Annual Budget Costs FY15 Total: $405,771.98 Direct Inmate/Canteen: $299,771.98 DPH Substance Use Grant: $77,200.00 RSAT Grant: $28,800.00 10
Warehouse for the Mentally Ill 197 or 51% of new intakes in January reported a history of mental illness 351 currently on psych meds (34% of total MSO inmate/detainee population) 372 have mental health caseloads (36% of total population) 74% report co-occurring substance use disorders 11
Caring for the Mentally Ill in the Absence of Community Based Resources In January 2017, 51% of ALL newly committed inmates reported a history of mental illness. 60% 2016 Mental Health Data 50% 40% 30% 20% 10% 0% January February March April May June July August September October November December NOTE: 74% those receiving mental health medication self-identified as having a co-occurring substance use disorder. 12
Innovative Collaborations Involving Mental Illness & the Criminal Justice System The Best Re-Entry Is No Entry Pretrial Diversion Bexar County model/regional holding facility Data-Driven Justice Initiative CIT Training Peer review Best practices Collaborations Information exchange 13
Housing Unit For Military Veterans (HUMV) Participation in the HUMV Unit is voluntary. Guiding principles are based on those incorporated in military life: Respect, Honor, Duty and Integrity. Creating a community among former military service personnel by fostering an environment of shared experiences and common goals. Programs specialized for veterans include substance use treatment, vocational programming, employment readiness, an exercise regiment, visits from the Department of Veterans Services, a weekly speaker s series and transitional assistance. 14
Medicaid Coverage for the Justice Involved: The Intersection Where Public Safety & Public Health Connect Individuals in the criminal justice system are in the greatest need of health care due to poverty, mental health and/or substance use disorders. Massachusetts was first in the nation to develop a comprehensive model for covering the uninsured. 2% of individuals in Massachusetts are without coverage But 25% of the individuals entering our facility do not have health insurance. 15
Affordable Care Act (ACA) & Medicaid Expansion Due to the ACA the majority of inmates have become Medicaid eligible because it is largely based on income. Also, under the ACA expanded services are available to treat mental health & substance use disorder, which impacts such a large portion of the individuals in custody. The future of Affordable Care Act remains in question. 16
Why This Matters Benefits of Insurance Coverage for the Justice-Involved: Greater continuity of care. Increasing the public safety & reducing recidivism. Saving valuable taxpayer dollars. 17
Areas of Focus Medicaid enrollment prior to release. Utilization the inmate exception for inpatient hospitalization. Suspending rather terminating Medicaid benefits for incarcerated individuals. 18
Health Insurance is Key to Recovery & Reducing Recidivism To create greater continuity of care and avoid gaps in coverage the MSO enrolls sentenced inmates 30 days prior to their release. To improve the enrollment process we worked with the State Legislature to pass legislation which suspends Medicaid benefits for inmates during incarceration, instead of terminating them. The implementation of this legislation will assist inmates transitioning back to the community gain access to the health care they need, reduce the rate of re-offense, and save valuable taxpayer dollars. Recent guidance from the Centers for Medicare and Medicaid Services concurred by strongly encouraging states to suspend rather than terminate Medicaid benefits for incarcerated individuals and are willing to provide resources to accommodate this change. For those battling mental health and substance use, continuity of care is critical and health insurance is key because individuals with coverage post-release will be able to gain access to treatment services immediately. 19
Questions Contact Information: Sheriff Peter J. Koutoujian sheriff@sdm.state.ma.us David Ryan, Policy Director dryan@sdm.state.ma.us 20