Prisoners are sicker than the general population. About 40% of prisoners report they have at least one serious chronic illness. Inmates are also at least seven times more likely to have a chronic hepatitis C infection. At Rikers, NYC Health & Hospitals estimates that 12% of the average daily population has hepatitis C.
Providing care to inmates isn't easy or cheap. California's Legislative Analyst's Office estimated that transporting, guarding and medically treating an inmate could cost more than $2,000 per day, and a Pew Charitable Trusts report found healthcare costs for prison inmates reached nearly $8 billion in 2011. That price tag continues to rise despite growing pressure to cut correctional facility budgets.
Many federal, state and local correctional facilities are turning to telemedicine as a cost-effective solution for providing high quality care. Telemedicine first sprang up in prisons in the 1990s as a way to provide specialty care for prisoners without ramping up transportation and security spending, according to the U.S. Justice Department.
It's taken longer for state and local jails to harness telemedicine, even though they incur more than 90% of the costs of corrections in the U.S., according to the Center for Economic and Policy Research in Washington, D.C.
NYC Health & Hospitals and Rikers are slowly and methodically rolling out the new technology. In May, the system funneled $650,000 into a pilot program. So far, only about a dozen doctors and patient coordinators engage in virtual visits, which are limited to infectious disease, gastroenterology and urology specialists.
“We have a broad aspiration to do more of this across services,” said Dr. Homer Venters, chief medical officer of Correctional Health Services, a division of NYC Health & Hospitals. “But when we start, we need to identify staff that are really going to champion this.” Venters previously oversaw New York City's correctional health program for the Department of Health and joined NYC Health & Hospitals when the system took the lead on the program.
Pham is one of those champions. The section chief of infectious disease at NYU Langone Medical Center's Hospital for Joint Diseases, Pham has treated Rikers Island inmates for eight years on an affiliate agreement between the health systems. “Vinh has been very dedicated to getting this project off the ground,” said Dr. Zachary Rosner, deputy director of medical services of Correctional Health Services.
Pham has seen his patients warm up to the virtual visits. During a visit, Pham sits in his office at Bellevue with a two-screen setup that allows him to see the patient and his or her electronic health record. The inmate joins the video conference from a clinical space on the island. Unshackled and accompanied by a patient navigator, the inmate can ask Pham about their condition and options for continuing care after leaving Rikers. Guards stand watch outside the room for confidentiality and security reasons.
The goal is to give hepatitis C patients the tools needed to manage their infection, Pham said, even if they're released earlier than expected. “I make it clear to the patients that this is about preventive health,” he said.
Hepatitis C drugs are notoriously expensive, costing up to $100,000 to for a year's worth of treatments. NYC Health & Hospitals has budgeted $2.5 million in fiscal 2017 for hepatitis C drugs, and $5 million in the ensuing years. In addition, it has partnered with Merck to receive discounts on its new hepatitis C treatment, Zepatier. Those initiatives should help the health system triple the number of inmates who will receive the treatment.
The virtual visits have also been used in gastroenterology and urology to provide test results, pre-op visits and evaluations for inmates with conditions including mild anemia, Crohn's disease, ulcerative colitis or difficulty with urinating.
“We've always viewed our role in correctional health as part of the public health system,” Rosner said. “When people are frustrated during a very difficult time for them, we do feel that having robust health systems in place can make a positive out of a very difficult situation.”
Although Rikers' telemedicine program has started small, the facility has a robust inmate intake program that could help NYC Health & Hospitals quickly ramp up telemedicine visits.
Upon entering Rikers Island's jail, each inmate gives a complete medical history and gets a physical examination, no matter the length of their stay. Correctional health providers will flag inmates that could benefit from specialist care or even a telemedicine visit during this process, Rosner said.
The intake process is comprehensive and can include HIV testing and vaccinations, according to Venters. “It's like a hospital admission,” he said.
For years, federal prisons have had a more robust telemedicine program than local and state jails do. Inmates in federal prison tend to serve much longer sentences and the Justice Department has supported using the technology for decades. An average stint at Rikers lasts 55 days, making it difficult for the local jail to even schedule specialist and telemedicine appointments before individuals leave.
In January, NYC Health & Hospitals formally took over the entire correctional health program for the city's jails. Venters said that helped Rikers get its telemedicine pilot program off the ground.
“We were a health system on the outside trying to innovate with a whole other organization,” he said. “Since we came into Health & Hospitals, we've become a whole family.”
Rikers and the health system are looking at several possibilities for expanding its telemedicine program, including psychiatric consultations and other specialty services. It also plans to add additional NYC Health & Hospital campuses to the telemedicine network.
“I see this as just the beginning,” Pham said. “I'm very optimistic.”