County “Creating a Hospital” for Its Jails?

With its latest action the Milwaukee County Board has begun legislating the parameters of its future medical services program for inmates in county custody. The task is not an easy one. 

In February, the board resolved to bring the operations for inmate medical services at the Milwaukee County Jail and the House of Corrections in-house by 2021. The county is ending a contract with Armor Correctional Health Services, a contract much maligned by the board, especially since the company’s fraudulent practices in the jail were uncovered and inmate in its care died. Taking Armor’s place on April 1 is another private contractor, Wellpath LLC. That firm will serve until the county’s in-house operation is up and running.

The legislation passed by the board last week Thursday lays the foundation for the county to begin building up a program that is certifiable by the National Commission on Correctional Healthcare. In the resolution the board specified their definition of self-operation as well as their desired governance structure.

Under self operation, Milwaukee County will staff positions with full time employees, as well workers from a pool or an agency, even independent contractors, to fill vacant or temporarily under-filled roles.

For self operation, Milwaukee County needs to be able to meet requirements laid out in the Christensen Decree, which is a legal settlement that gives the courts continuing jurisdiction over the county’s compliance with the settlement. Part of meeting its requirements means staffing at least 128 full time positions in order to reach a certain number of hours of medical, psychiatric and dental care. Staffing a correctional medical service is a task fraught with complications.

As Sup. Sheldon Wasserman, a physician himself said, “What we’re basically creating is a hospital within the corrections facility.”

This is because along with the all the actual care givers, Milwaukee County will need to develop a back office of individuals working on compliance, leadership, finance etc. which has been provided through the corporate office of private contractors like Armor (and soon WellPath).

Milwaukee County’s own history providing medical care to inmates may provide a window into the importance of such back office operations. Up until 1995, Milwaukee County ran a hospital, County General, later named John L. Doyne Hospital. So Milwaukee County had an extensive medical administrative apparatus in the hospital, out of which they ran their inmate medical services. This provided all the back office support, along with a large pool of medical staff to train, cross train and use as a pool for the inmates medical needs. Teig Whaley-Smith, the county’s director of administrative services, said that a possible narrative for “why we failed doing inmate medical” is “because we didn’t have that back office operation and we weren’t running a hospital anymore.”

The Christensen Decree, which hangs over everything the county does in the jail and the House of Corrections, stemmed from a lawsuit that was filed in 1996.

Along with losing the back office, selling the hospital meant the county lost a pool of experienced medical professionals from which they could draw for work in the jails. Hiring for and keeping positions filled has been a problem for Armor and it will likely be one for the county under self operation.

There is a nationwide nursing shortage, so hiring nurses to work in a jail setting is doubly hard. Deputy Inspector Aaron Dobson, commander of the Milwaukee County Jail, said, “It is very difficult to hire, it was difficult for us when we self operated, it was difficult for Armor now and it will be difficult for Wellpath, honestly.”

Getting competent medical professionals to work in a jail setting requires you to pay them handsomely, as Dobson, Wasserman and county Comptroller Scott Manske noted. “Be prepared to pay some big money,” Wasserman warned his colleagues at Thursday’s meeting.

Compensation is also the key to keeping staff on board. And failure to heed this advice can have terrible results. Wasserman noted his experience serving on the state medical board and witnessing problems first hand at the state prisons: “I hate to say it, bottom of the barrel individuals work in jails, because that’s the only job they can get.” Without high level pay, Wasserman said, these jobs tend to attract physicians and medical staff with “long previous records of drug convictions, drug violations, substance abuse issues, psychiatric health.”

Manske and Wasserman have both suggested partnering with a local medical institution to help with nursing shortages or filling positions. Manske said when the county ran their own operation burn-out and overtime costs among the nursing staff were major issues for the county. Working with another institution could help, perhaps, by providing a pool of nurses to draw from. Wasserman suggested the Medical College of Wisconsin.

Another key piece of the legislation passed by the board Thursday was the definition of governance for the future program. What the board landed on was a model of direct reporting to the County Executive. What this does is allow the county Department of Administration to, essentially, build a new department from the ground up, instead of developing a division within an existing department like the Department of Health and Human Services or the Behavioral Health Department. The latter being a particularly thorny option for the board because they have no oversight of the Department of Behavioral Health. That body is overseen by the Mental Health Board, an unelected body.

Setting up the program this way means that when the board sees its first price tag for the whole inmate medical operation it will likely be the highest possible variation in costs, said Erin Schaffer, the special project manager for the inmate medical program. But, after that, the county can look for redundancies and operations that can be filled in or supported by other existing county departments, and pare down the final cost.

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