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CorrectCare
You Need an OTC
Commissary in Your Facility!
by Jeffrey
E. Keller, MD, FACEP
When I was an
undergraduate, before I switched to premed, I was an economics
major. Maybe because of that training, when I look at jail
medical practices, I tend to look at all of the costs of medical
practice, not just the monetary costs. For example, the total
cost of providing a medication to a patient in the jail includes
the cost of the medication (of course), but it also includes the
cost of the various people, like nurses, pharmacists, deputies
and practitioners, who spend time creating the prescription.
Thinking of costs in this way can change our perspective of what
something “costs.”
Consider the
case of the man with heartburn. We’ll call him “Jeffrey.” He
doesn’t know it, but he is about to go to jail. Before Jeffrey
goes to jail, if he wants to purchase something like ranitidine
(Zantac) for his heartburn, he would go to a store and buy it.
He doesn’t need to see a medical professional. He doesn’t need a
prescription. In most places, he doesn’t even need to
wait—convenience stores sell ranitidine 24/7. The monetary price
Jeffrey will pay for 50 tablets of ranitidine at the store is
around $7. The cost in terms of time is how long it takes him to
run to the store. The total cost in time to the store to provide
the ranitidine to Jeffrey is 30 seconds—how long it took the
store clerk to ring up the sale.
Now think of
the same guy in jail. Jeffrey still has heartburn. Let’s say he
still has money—now in his commissary account. He is still
willing to buy ranitidine. But ranitidine is not on the jail
commissary list. He can buy ramen noodles or a Snickers bar, but
not ranitidine. To get it, he has to put in a “request for
medical care” form. What happens now varies from jail to jail
and prison to prison. I am going to present a typical jail
scenario.
Breaking It
Down
The act of requesting
nonemergent medical care costs Jeffrey $10. The form is then
triaged by a nurse and Jeffrey is scheduled to see a
practitioner. Since the clinics are crowded, the appointment is
made for five days hence. In the meantime, he continues to have
heartburn. On the scheduled day, he comes to the medical clinic.
He waits, say, an hour in the waiting area. He then has vitals
taken by a nurse. The practitioner, unsurprisingly, orders a
prescription of ranitidine for Jeffrey. The order is sent to the
pharmacy and is delivered the next day. It is paid for from the
jail medical budget.
Total monetary
cost to Jeffrey is $10. Total monetary cost of the prescription
to the jail is around $6. Total price to everybody in time is,
well ... a lot. Jeffrey had to wait five days. The jail medical
staff had to process and triage the request for medical services
(10 minutes total?). A nurse and a practitioner had to see the
patient in clinic (another 15 minutes total between the two?). A
chart is generated, which then has to be filed (30 minutes?).
Deputies spent some time getting the patient to the clinic and
back. The pharmacist spent time filling the prescription. The
UPS/FedEx delivery service ... well, you get the drift.
It doesn’t
matter if I am overestimating the time. Just remember that we
have to multiply whatever time figure we come up with by every
request for an over-the-counter product that is handled this
way. Not just ranitidine, but also foot fungus cream, cough
drops, rash cream, ibuprofen, acne cream, nasal spray and on and
on.
Why not put OTC
medical items on the commissary and let inmates purchase them
without having to go through the medical service?
This seems to
me like a no-brainer all the way around. Put the ranitidine on
the jail OTC commissary so that Jeffrey can purchase it without
having to involve the medical staff. Jeffrey benefits by having
much easier access to OTC products at a cheaper price. The
medical staff benefits by not having to deal with requests for
OTC products and having that much more time to spend with truly
sick patients.
I can hear you
objecting: “We don’t charge inmates a fee to access medical
clinic.” “Nurses can give inmates a week’s supply of OTCs; the
inmate does not have to see the practitioner.” These objections
miss the point that the main cost of making inmates go through
“the system” to get OTC medications is time! The savings in time
to nurses, for example, allows them to spend more time with
truly sick and needy patients.
Factors to
Consider
If you decide to set up
an OTC commissary system, here are a couple of items to
consider.
Indigence. What
happens if Jeffrey has no money on his books? One way to deal
with this is to allow indigent inmates to buy certain medical
commissary items on credit (meaning that they “go into the hole”
with their books, and if they ever get funds, the money is paid
back). Another is for the jail just to absorb the cost of
certain medical OTC products for indigent inmates—that is still
cheaper than making them kite and go to clinic. The jail pays
for the medication either way!
Inappropriate
OTC items. Certain items that are available OTC at your local
store should not, in my opinion, be offered on a jail
commissary. This includes any item that can be abused or that
can cause serious harm when taken in overdose. I would include
the following: dextromethorphan cough medicine, Benadryl and
other first-generation antihistamines (though I would allow
purchase of second-generation OTC antihistamines, like Claritin)
and pseudoephedrine (used in meth production). No Ex-Lax, of
course! Too tempting to play practical jokes on your neighbors!
Sometimes,
inmates don’t like purchasing medical items from the commissary.
They get it free if they go through the medical clinic. Time is
not as important to them as it is for us. The solution is to
make purchasing OTC items from the commissary cheaper than going
through medical. Here’s one way to do this is this: When an
inmate comes to the medical clinic requesting, say, ranitidine,
rather than ordering the item through the pharmacy, pull the
item from the commissary and charge the inmate a small “urgent
access fee.” The idea is that you want it to be cheaper and
easier for inmates to purchase commissary items without going
through the clinic.
Stocking the
Shelves
What items can be offered
on an OTC commissary? Remember that any OTC medical item you do
not make available on the commissary can be obtained only by an
inmate by going through the medical process. Here is one
possible list:
A. Rash medications
1.
Antifungal foot cream
2. Hydrocortisone cream
3. Benadryl cream
B. Acne medications
1. Stridex
pads
2. Benzoyl peroxide
C. Stomach medications
1. Antacids
(Rolaids)
2. Ranitidine
3. Omeprazole
4. Gas-X
5. Beano
D. Diarrhea medications
1. Fiber
tablets or Metamucil
2. Pepto-Bismol
3. Imodium
4. Kaopectate
E. Constipation medications
1. Fiber
tablets or Metamucil
2. Stool softeners (Colace)
F. Diet supplements
1. Vitamins
2. Calcium
3. Lactaid (for lactose intolerance)
G. Cold and flu medications
1. Saline
nasal spray
2. Afrin nasal spray
3. Cough drops
4. Sore throat lozenges
5. Loratadine (but not other antihistamines or
decongestants)
6. Ibuprofen
H. Muscle ache remedies
1. Muscle
rub
2. Ibuprofen
I. Psoriasis and dandruff
medications
1. Dandruff
shampoo
2. Coal tar shampoo
3. Coal tar lotion
4. Hydrocortisone cream
—
About the author: Jeffrey
E. Keller, MD, FACEP, is the president of Badger Correctional
Medicine, Idaho Falls, ID. Contact him at
jkeller@badgermedicine.com.
[This article first appeared in the
Spring 2011 issue of CorrectCare.] |
