As reported by The Hartford Courant, May 15, 2005.

Jailhouse Medicine: A Million-Dollar Patient

By Robert A. Frahm

When the University of Connecticut Health Center's budget tipped into the red this year, officials blamed the cost of a single patient - a prison inmate whose pharmacy bill topped $1 million.

The Health Center handles medical care for state prisons under an arrangement designed to keep medical costs in check, but the high cost of treating this one inmate, who has a serious blood disorder and three years ago had an even larger bill, came as a financial jolt.

"We run a pretty tight ship, but when a million-dollar cost comes out of nowhere and breaks the bank ... the issue becomes: Who pays for it?" said David L. Budlong, executive director of UConn's Correctional Managed Health Care Program.

UConn has asked for reimbursement from the state Department of Correction, which, in turn, has requested a special appropriation from the legislature.

Aside from monitoring costs, officials from several state agencies have met jointly to develop plans for the inmate's continued care and his transition to the community - including efforts to keep him from committing new crimes to gain access to prison medical services. He was jailed earlier this year on a larceny charge but was released recently and is on probation, a prison official said.

The inmate, a heroin user in his early 30s, has been in and out of prison over the past decade. He is believed to be the most expensive patient in the 10 years since UConn has handled medical care for state prisoners.

When the man was arrested again last year, a doctor e-mailed top UConn officials to alert them that the high-cost patient had been admitted to the university's John Dempsey Hospital even before his court date. "The Million Dollar Man is back," the e-mail said.

The latest pharmacy bill of $1.1 million, including the cost of a rarely used coagulant to treat bleeding disorders such as hemophilia, was the result of treatments over several weeks late in 2004, including a single day's treatment in December that cost more than a quarter of a million dollars, according to documents obtained by The Courant under the state's Freedom of Information Act.

UConn refused to pay a pharmacy bill of $1.3 million for the same patient in 2002, the same year the university's Correctional Managed Health Care Program laid off 36 workers to offset a $2 million budget reduction.

That bill eventually was paid by the Department of Correction.

Although the million-dollar drug treatment is a rarity, similar extraordinary medical cases elsewhere have highlighted the growing cost of health care in the nation's prisons. One widely publicized case occurred in California, where a convicted robber received a state-funded heart transplant three years ago. The inmate, whose transplant stirred a statewide controversy, died about a year later.

The right of prisoners to receive standard medical care has been established under various court rulings, including a 1976 U.S. Supreme Court decision that said "deliberate indifference" to an inmate's medical needs violates the constitutional ban against "cruel and unusual punishment."

"I would argue, because someone is incarcerated, we have a higher obligation to provide them care because we have deprived them of their liberty," said Dr. Michael A. Grodin, director of medical ethics at the Boston University School of Medicine and Public Health.

"One of the only places you have a legal right to health care in this country is if you're in prison," he said. "Paradoxically, it may mean better care because 45 million people in the country have access to no health care."

Patricia A. Ottolini, director of health and addiction services for Connecticut's correction department, said, "With 18,500 inmates, somewhere in that number we're going to have extraordinary costs."

Officials at UConn and the correction department refused to identify the inmate with the blood disorder and would not discuss details of his case, citing federal patient privacy laws.

Nevertheless, state records, including e-mails and letters about the case, describe the man as a habitual criminal who has been transferred frequently to Dempsey Hospital while he was imprisoned periodically at Somers and Uncasville over the past decade.

He has been jailed for various offenses, including violation of probation, possession of drugs and larceny.

"On the street, he uses heroin to control pain and depression. All arrests were due to stealing to buy heroin," a doctor wrote in one memo earlier this year.

What made his treatment so expensive was the use of a relatively new drug known as Factor 7A, most commonly used to treat hemophilia patients who do not respond to more conventional forms of therapy.

The drug, produced by the Danish-based company Novo Nordisk Inc., is made using genetic engineering techniques. It is costly to develop but can be lifesaving, said Dr. Harold R. Roberts of the University of North Carolina at Chapel Hill, a specialist who has written about the use of Factor 7A.

Connecticut is one of only a handful of states with a partnership between a university medical center and a prison system. The UConn Health Center provides medical, mental health, pharmacy and dental services for inmates. The program, part of the Health Center's public service mission, provides services at all of the state's prisons and jails. Its budget this year is $81 million.

Aside from providing a training ground for medical and dental students, the arrangement is considered to be safer, more manageable and more efficient than sending inmates to private doctors and hospitals.

Nevertheless, several factors continue to push costs up. "The drugs keep getting more expensive for us, and we are getting sicker patients," said Budlong, the program director.

A report by UConn to the legislature earlier this year said the prison population "is proportionately sicker than the general population on virtually any measure of mental illness and chronic and communicable diseases."

The report said, for example, that the number of inmates on medications is up 46 percent since 1999 in the state. The occurrence of diabetes and hypertension among inmates has roughly doubled over the same period.

The aging prison population and growing level of medical need illustrates a need to focus on education and prevention of illness, said Claire Leonardi, chairwoman of the UConn Health Center's board of directors.

"This is not about one patient and a million-dollar drug," she said. "We'd love the [UConn program] to be a national model of care for inmates - prevention, diagnostics, early detection."

Although the program has been able to hold overall pharmaceutical costs down through a nationwide purchasing consortium, the cost can still be high. Interferon treatment for an inmate with hepatitis C, for instance, costs about $35,000 a year, according to the report to the legislature.

"New medications, new therapies - those costs all add up," said Edward A. Harrison, president of the Chicago-based National Commission on Correctional Health Care. The cost of treating inmates "is definitely a big issue. We get a lot of calls on it."

A U.S. Bureau of Justice Statistics report in 2001 said Connecticut spent $3,620 per inmate on medical care, well above the national average of $2,625 but less than several other states. Maine reported the highest cost, $5,601. Nevertheless, the report said spending on health care for inmates nationwide averaged just over $7 a day, compared with nearly $12 a day for U.S. residents.

In Connecticut, the cost of treatment for the inmate with the blood disorder was so extraordinary that it became one of the issues under discussion as UConn and the correction department work on a revision of their partnership agreement.

Two years ago, as the inmate was being released from prison to a supervised program for his transition to the community, officials recommended assisting him in applying for Medicaid benefits. Those benefits "could keep him from re-offending to get back into the health care offered" in prison, said an e-mail from Carol Salsbury, deputy commissioner in the correction department.

More recently, officials from several state agencies - including UConn, the correction department, the Department of Mental Health and Addiction Services, the state budget office and parole and probation officials - have met to discuss the inmate's ongoing need for care, including treatment for drug addiction.

"Merely assisting him with [his] release [from prison] will not address the financial, custodial, medical, substance abuse, and potential human rights problems that this individual represents," Dan Bannish, health services program director for the correction department, wrote in February.

The objective, Bannish said recently, is to create a comprehensive state plan for him.

"Whether he's out [of prison] or in, it will impact us one way or another," he said. "It's not [just] a corrections issue, not a probation issue. It's a state issue, top to bottom."