Caring for incarcerated individuals

By Emily Margosian, Assistant Editor, June 1, 2022

Nearly two million people are currently incarcerated in the United States — more than the rate of any other nation in the world at 573 per 100,000 residents. Despite the steep growth in the number of incarcerated Americans over the past 20 years, this population is often overlooked within the wider health care system, supported by a patchwork of individual state policies.

Although correctional facilities are required to provide medical care, access to specialty care is often limited, with demand outpacing supply. Studies show a high prevalence of skin disease among the incarcerated, with the onset of the COVID-19 pandemic further isolating an already vulnerable population from adequate access to dermatologic care.

This month, DermWorld speaks with dermatologists who care for incarcerated patients to discuss commonly observed conditions, care delivery challenges, and opportunities for expanding access.

Commonly observed skin conditions among the incarcerated

Jun Lu, MD, FAAD, associate professor of dermatology at UConn Health, has been treating incarcerated patients for the past five years in collaboration with the Connecticut Department of Corrections (DOC), offering both telehealth and in-person care to inmates. According to Dr. Lu, “It’s really a wide spectrum, but in my experience, patients tend to have a higher incidence of significant inflammatory skin conditions such as severe acne, atopic dermatitis, psoriasis, and hidradenitis suppurativa. Skin cancers and concerning growths or lesions are also very common.”

“The patients in general really need us. We’re seeing things that have been referred to us by prison clinicians who feel that the patient needs a specialist, so they tend to have more challenging disease.”

“It’s a mix of inflammatory disease,” agreed Daniel Bennett, MD, FAAD, associate professor and vice chair of clinical affairs in the department of dermatology at the University Wisconsin-Madison (UWM) School of Medicine and Public Health, and Academy Secretary-Treasurer. Dr. Bennett has been involved with UWM’s bi-monthly inmate dermatology clinic in partnership with the Wisconsin Department of Corrections for the past 10 years. “The patients in general really need us. We’re seeing things that have been referred to us by prison clinicians who feel that the patient needs a specialist, so they tend to have more challenging disease,” he explained. “There is also a skin cancer component to it. I’ve been surprised by the number of transplant patients that are in our prison system, so they come to our clinic for routine skin cancer exams as well.”

Reach of teledermatology

While the adoption of teledermatology has rapidly expanded since the start of COVID, the model has long been a natural fit as a form of care delivery within the prison system. Bethany Lewis, MD, MPH, FAAD, assistant professor of dermatology at the University of Utah, currently oversees the department’s nearly 20-year-old prison teledermatology clinic. “The University of Utah has been quite innovative in this realm, given the uniqueness of our position in the intermountain west, which is a very rural area,” she explained. “Live-video teledermatology has been a resource we’ve used for a very long time — initially for the prison starting in 2003, which has since been expanded to serve the county jail population as well.”

According to Dr. Lewis, most inflammatory skin conditions can be diagnosed and managed successfully via telemedicine. “We see a strikingly large percentage of chronic psoriasis, as well as some notably difficult to treat lichen planus patients and dermatitis NOS. We can also treat and manage severe cases of acne fairly well via teledermatology,” she said.

Dr. Lu, who helped establish the telemedicine service offered by UConn, says that it has significantly broadened access for incarcerated patients since its addition. “UConn dermatology has had a long collaboration with the Connecticut DOC. In the past, because of the complexity of the social situation surrounding these patients, usually their access to dermatology care was very limited.”

Often, in-person specialty care for inmates is restricted by the need for special transportation, the availability of law enforcement escorts, and available clinic space separate from other patients. “That really limits their access and was resulting in a big backlog of patients that needed to be seen. Now we’re doing a combination module of teledermatology and in-person service. Patients who can be seen via teledermatology are triaged there, and the patients who need in-person care can be seen faster. We’ve been able to offer services to a lot more patients as a result,” said Dr. Lu, who was recognized in 2021 with an AAD Patient Care Hero award for the use of telemedicine to improve the health and wellbeing of women who have been incarcerated.

“The addition of telederm as a big part of the service has also helped a lot with follow-up care. For example, if we have a patient who has been seen in-person, has a clear diagnosis of psoriasis, and needs to start biologics, all the follow ups can be done just by telederm periodically,” said Dr. Lu. “We do a secured transfer of photos and a live video communication so that the patient can still have good quality of care during their follow ups, without having to be delayed because of the limited access to in-person visits.”

Live visits

Despite the extended reach of teledermatology for inmate care, not all conditions can be appropriately managed without hands-on assessment and treatment. “Patients who need a procedure — for example, biopsies, injections, or incisions, or are at a high risk of skin cancer and need regular full-body skin exams — those types of patients need to be seen in person,” explained Dr. Lu.

Incarcerated patients who present with an unclear diagnosis, unfavorable reaction to treatment, or oral lesions are also likely to be poor candidates for virtual visits, according to Dr. Lewis. “For example, some pigmented lesions can be difficult to feel confident about via teledermatology. There are also rashes that can be incredibly difficult to visualize through live teledermatology or are more ambiguous and require a biopsy.”

However, while in-person care may be required for some incarcerated patients, it requires a heightened level of logistical coordination beyond that of a typical patient. “For security reasons, patients must be seen in a clinic space that’s directly attached to our main hospital. We don’t have a dermatology clinic in that space, so we have to borrow surgery clinic space to see those patients,” explained Dr. Bennett. “Transportation is also an issue. Nearly every clinic, we have at least one patient who has canceled because of a transportation problem. Timing is also a complication. This clinic is only held the first and third Thursday of the month, so if I get a call that a patient has an explosive, painful rash, and it’s Monday of the fourth week of the month, I have no way to see that patient until that next Thursday. That also puts limits on what we can do — for example, patch testing — because there’s no way we can see them multiple times in one week.”

“Most violence against physicians has typically been perpetrated by patients they see in routine parts of their job. I’ve never seen any data to suggest that providing care to incarcerated patients puts you at significantly higher risk for violence than any other practice we have.”

The determined care site for incarcerated patients can also vary depending on their deemed level of risk. “We don’t know how they’re classified, but you can tell because some are brought in with an attendant and they’re not in restraints; others are brought in with armed guards and are heavily shackled,” said Dr. Bennett. “Roughly once a year, we have patients who are deemed high enough risk that they ask us to come to a secure holding facility within our hospital to treat them.”

As far as physician safety, “I personally don’t take any precautions beyond the protocol my institution requires,” explained Dr. Bennett. “The patients are like patients anywhere else; they can request their medical records and have access to our names. This may sound cynical, but most violence against physicians has typically been perpetrated by patients they see in routine parts of their job. I’ve never seen any data to suggest that providing care to incarcerated patients puts you at significantly higher risk for violence than any other practice we have.”

Inmate referral for dermatology care

The referral process for dermatology care can vary between institutions. In some cases, it is requested by the patient; in others, prison medical staff may refer a patient to a dermatologist for specialty care. In most cases, however, the attending dermatologist will decide whether to triage the patient to a virtual or face-to-face visit.

“We have a very close relationship with the primary care providers and administrators in the DOC,” said Dr. Lu. “I actually gave a grand round talk to the prison primary care providers about what is suitable for telederm and what is suitable for in-person service, so they have a general idea. Our triage coordinator is part of the DOC; they collect all the referrals for dermatology into a bulk of referral requests with a summary of the patient’s history and their skin concerns. They send it to me, and I review all the consult requests and triage them.”

Health care coverage for the incarcerated

The question of who pays for health care for the incarcerated is often opaque and varies state by state. In some cases, telehealth services may be covered by Medicaid; in others, the state’s DOC may pick up the bill.

“All incarcerated patients, at least in Connecticut, are on Connecticut Medicaid. So, they are basically covered by public insurance through Medicaid or Medicare, and they pay as they would pay for any other patient,” explained Dr. Lu. “Right now, there is a specific payment code for telederm — either an audio or video visit — and if they were seen in-person, they would be charged for a visit just like everybody else. How much the state Medicaid covers telederm varies a lot, but at least in Connecticut we have pretty good coverage so far for the services we provide.”

“It’s not something I’m completely clear on,” admitted Dr. Lewis. “It’s entirely taxpayer funded, is what I’ve been told. Basically, it operates as its own sort of health care system in a way. We bill as we would any sort of regular visit and it’s reimbursed to a certain percentage.”

Care delivery challenges

As with normal practice, communication between providers and lack of EHR interoperability also poses problems when caring for the incarcerated. “Our biggest logistical problem is really communication, and getting information from the prison about labs, other specialty referrals, or primary care notes,” said Dr. Bennett. “Communication with the prison is not great. We don’t have a shared medical record system with them, and they are not always proactive about sharing information with us. I frequently find myself making recommendations for them, and I have to leave it to them to do it. It’s a very consultative clinic. With only a couple of exceptions, we don’t order medications; we don’t order labs. We tell the prison what we believe they should do, and 95% of the time, they follow our recommendations.”

Dr. Lewis agrees that a lack of communication and shared records between dermatologists and prison primary care providers often makes continuity of care challenging. “It’s tricky. We will get referrals emailed to us in advance, which include a very peremptory, short summary of what they want to be seen for, as well as meds and other diagnoses that they have on their chart. It’s very limited, and we really rely on our own recordkeeping. If a patient has been seen repeatedly, for chronic plaque psoriasis, for example, we’re documenting that and watching it in our own EMR,” she explained. “Otherwise, we don’t have a ton of information from physicians that they might be seeing at the prison. Sharing labs and medication monitoring becomes difficult; that kind of stuff is where the cracks become a little bit more obvious.”

As in many other facets of life, COVID-19 also caused significant disruption within the prison health care system, particularly as many institutions have grappled to control outbreaks among their inmate population. “The prisons were, for obvious reasons, very stressed. They had COVID outbreaks; they didn’t have the staff to transport patients to clinic. During that time, I did spend more time on the phone with prison clinicians trying to talk them through what to do for my established patients,” said Dr. Bennett. “Ultimately, you’re navigating the care of a patient in collaboration with prison clinicians who are also working in a stressed and underfunded system. It’s not their fault, and they’re trying to do their best as well, so I try to have empathy.”

Follow up can also prove challenging, particularly if a patient is unexpectedly discharged from prison. “In these cases, it’s important to establish a relationship with both patients and the on-site primary care provider. We don’t necessarily know when a patient will be discharged from the facility, but we can let the primary care provider know what the patient’s needs are once they’re discharged,” explained Dr. Lu. “The facility’s primary care provider will try to set it up for them before they leave, and since they are already an established patient, we do our best to try to accommodate them. However, because of the complicated social situation surrounding these patients, they may not necessarily always be present for their scheduled follow-up visit.”

Dr. Bennett agrees that despite best efforts, ensuring follow-up care among this patient population can be uniquely challenging. “If a patient happens to live close to where I’m based, then they can follow up with me. Of course, it’s a big enough state that not everybody has the ability to drive to Madison. The best I can do is coach them. I routinely ask if they’re due to be released soon. Once they know their release date, I usually start talking to them about working with a social worker to make sure they’re set up with appropriate insurance coverage and how to find a dermatologist. While I’ve had several patients follow up with me in my routine clinic, I’ve also had a number get reincarcerated. Patients can also be frequently transferred from one prison to another, which causes significant discontinuity in care, because it relies on the next prison’s clinicians to decide they need to see a dermatologist.”

Patient and physician impact

Despite these hurdles, the rewards of providing dermatology care to incarcerated patients are worth the challenge, according to Dr. Bennett. “When I talk about this clinic, the thing I fundamentally love about it is that it reminds us as physicians that we’re there to care for patients as they are, and not to make judgments about whether they deserve care. I don’t ever ask why they’re incarcerated, but not infrequently addiction comes up. I don’t think many dermatologists are aware of how many people are incarcerated for non-violent crimes resulting from addiction or mental health disorders that are going untreated. These are human beings who are suffering, and it’s our job to alleviate that suffering regardless of who they are.”

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